National Health Insurance Act

Municipalities and Societies must pay to health insurance-covered medical institutions, etc. expenses relating to benefits for medical treatment. The amount of expenses which may be claimed by a health insurance-covered medical institution, etc. from a Municipality or Society in relation to benefits for medical treatment shall be calculated by deducting the amount of any co-payment payable to such health insurance-covered medical institution, etc. by the insured person (or the Householder or Society member of the household to which such insured person belongs in the case set forth in Article 57) in relation to the benefits for medical treatment from the amount of expenses incurred in providing said benefits for medical treatment.

Calculation of the amount of expenses incurred in providing the benefits for medical treatment set forth in the preceding paragraph shall be governed by the same rules as those prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 76, paragraph (2) of the Health Insurance Act.

Municipalities and Societies may, with the authorization of the prefectural governor, specify otherwise in a contract with a health insurance-covered medical institution, etc. with respect to the amount of expenses incurred in providing the benefits for medical treatment set forth in paragraph (1) for the medical treatment to be provided at such health insurance-covered medical institution, etc., within the range of the amount calculated pursuant to the provisions of the preceding paragraph.

Upon receipt of a claim by a health insurance-covered medical institution, etc. for expenses incurred in providing benefits for medical treatment, Municipalities and Societies shall make payment after conducting an examination according to the rules set forth in Article 40, and according to the method for calculating the amount set forth in paragraph (2), and the provisions of the preceding paragraph.

Municipalities and Societies may entrust affairs concerning the examination and payment pursuant to the provisions of the preceding paragraph to a Federation of National Health Insurance Associations whose jurisdiction covers the area of a prefecture (excluding any such Federation the number of whose member prefectures, Municipalities and Societies is less than two-thirds of the total number of prefectures, Municipalities and Societies located within its jurisdiction) or the Medical Information Infrastructure and Medical Fee Examination and Payment Organization (hereinafter referred to as "the organization") under the Act on the Medical Information Infrastructure and Medical Fee Examination and Payment Organization (Act No. 129 of 1948).

Of the affairs concerning the review of medical bills conducted by a Federation of National Health Insurance Associations as entrusted pursuant to the provisions of the preceding paragraph or those of Article 76, paragraph (5) of the Health Insurance Act, those concerned with the review of such medical bills as specified by the Minister of Health, Labour and Welfare may be entrusted by such Federation of National Health Insurance Associations to any of those general incorporated associations or general foundations designated by the Minister of Health, Labour and Welfare as those meeting the requirements specified by Ordinance of the Ministry of Health, Labour and Welfare in terms of the organization involved in such review and other matters, and as capable of conducting such affairs in a proper and reliable manner.

An entity to which affairs concerning the review of medical bills as specified by the Minster of Health, Labour and Welfare pursuant to the provisions of the preceding paragraph have been entrusted must have the review of such medical bills conducted by a person who meets the requirements specified by Ordinance of the Ministry of Health, Labour and Welfare.

In addition to what is provided for in each of the preceding paragraphs, necessary particulars concerning claims for expenses incurred in providing benefits for medical treatment by Health Insurance-Covered Medical Institutions, etc. shall be prescribed by Ordinance of the Ministry of Health, Labour and Welfare.

When the Minister of Health, Labour and Welfare or a prefectural governor finds it necessary in relation to benefits for medical treatment, said minister or governor may order a Health Insurance-Covered Medical Institution, etc. or any of the persons who were establishers or administrators, health insurance-covered physicians, health insurance-covered pharmacists or other employees of a Health Insurance-Covered Medical Institution, etc. (hereinafter referred to as "Former Establishers, etc." in this paragraph) to make a report or submit or present medical records or other books and other documents, may request any of the establishers, administrators, health insurance-covered physicians, health insurance-covered pharmacists or other employees of a Health Insurance-Covered Medical Institution, etc. (including Former Establishers, etc.) to appear, or may have personnel question persons involved or inspect any equipment or medical records, the books and other documents or other articles of such Health Insurance-Covered Medical Institution, etc.

In cases where questions are asked or inspections are conducted pursuant to the provisions of the preceding paragraph, the relevant personnel must carry an identification card and present it at the request of any person concerned.

The authority under paragraph (1) must not be construed as being granted for criminal investigation.

The provisions of Article 41, paragraph (2) shall apply mutatis mutandis to questions asked or inspections conducted pursuant to the provisions of paragraph (1).

When a prefectural governor finds it necessary that a disposition be made pursuant to the provisions of Article 80 of the Health Insurance Act with respect to a Health Insurance-Covered Medical Institution, etc. in relation to benefits for medical treatment provided under this Act or that a disposition be made pursuant to the provisions of Article 81 of the Health Insurance Act with respect to a health insurance-covered physician or health insurance-covered pharmacist in relation to medical care or prescription service provided under this Act, said governor must notify the Minister of Health, Labour and Welfare thereof, together with the reason therefor.

The provisions of Article 64 and Article 82, paragraph (1) of the Health Insurance Act shall apply mutatis mutandis to benefits for medical treatment provided under this Act. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.

With respect to expenses incurred in Dietary Treatment received by an insured person (excluding a Person Specified as Hospitalized Long-term and Insured) in combination with the medical treatment listed in Article 36, paragraph (1), item (v) at or from the health insurance-covered medical institution of said person's choice, Municipalities and Societies shall pay expenses for Dietary Treatment for inpatients to the Householder or Society member of the household to which said insured person belongs; provided, however, that this shall not apply during any period in which said Householder or Society member is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to said insured person.

The expenses for Dietary Treatment for inpatients shall be calculated by deducting the amount of standard co-payment for Dietary Treatment set forth in Article 85, paragraph (2) of the Health Insurance Act (hereinafter simply referred to as "Standard Co-payment for Dietary Treatment") from the amount of expenses calculated for said Dietary Treatment in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the same paragraph (or, when said amount exceeds the amount of expenses actually incurred for said Dietary Treatment, the amount of expenses actually incurred for said Dietary Treatment).

When an insured person has received Dietary Treatment at or from a health insurance-covered medical institution, Municipalities and Societies may, on behalf of the Householder or Society member of the household to which said insured person belongs, pay to said health insurance-covered medical institution expenses incurred for said Dietary Treatment payable by such Householder or Society member to said health insurance-covered medical institution, within the limit of the amount payable to such Householder or Society member as expenses for Dietary Treatment for inpatients.

When a payment has been made pursuant to the provisions of the preceding paragraph, the Householder or Society member shall be deemed to have received expenses for Dietary Treatment for inpatients.

Upon acceptance of a payment of expenses incurred for Dietary Treatment, the Health Insurance-Covered Medical Institution must, pursuant to the provisions of Ordinance of the Ministry of Health, Labour and Welfare, issue a receipt therefor to the Householder or Society member who makes such payment.

The provisions of Article 64 of the Health Insurance Act and paragraph (3) of Article 36, Articles 40 and 41, paragraphs (3) through (8) of Article 45 and Article 45-2 of this Act shall apply mutatis mutandis to Dietary Treatment received at or from an Health Insurance-Covered Medical Institution and to the payment of expenses for Dietary Treatment for inpatients associated with such treatment. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.

With respect to expenses incurred in Living Support received by a Person Specified as Hospitalized Long-term and Insured in combination with the medical treatment listed in Article 36, paragraph (1), item (v) at or from the health insurance-covered medical institution of said person's choice, Municipalities and Societies shall pay Living Support expenses for inpatients to the Householder or Society member of the household to which such Person Specified as Hospitalized Long-term and Insured belongs; provided, however, that this shall not apply during any period in which said Householder or Society member is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to such Person Specified as Hospitalized Long-term and Insured.

The amount of Living Support expenses for inpatients shall be calculated by deducting the amount of Standard Co-payment for Dietary Treatment set forth in Article 85-2, paragraph (2) of the Health Insurance Act (hereinafter referred to as "Standard Living Expense Co-payment") from the Living Support expenses calculated in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the same paragraph (or, when said amount exceeds the actual amount of Living Support expenses, such actual amount of Living Support expenses).

The provisions of Article 64 of the Health Insurance Act and paragraph (3) of Article 36, Articles 40 and 41, paragraphs (3) through (8) of Article 45, Article 45-2 and paragraphs (3) through (5) of the preceding Article of this Act shall apply mutatis mutandis to Living Support received at or from a Health Insurance-Covered Medical Institution and to the payment of Living Support expenses for inpatients associated with such treatment. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.