National Health Insurance Act

In order to ensure the smooth and reliable implementation of national health insurance services, including the provision of insurance benefits, and to adjust finances in accordance with the financial condition and other circumstances of the Municipalities within the prefecture, each prefecture shall, pursuant to Cabinet Order provisions, by Prefectural Ordinance, provide subsidies for national health insurance benefit expenses, etc. to the Municipalities within that prefecture with respect to the cost incurred in providing benefits for medical treatment, etc., the expenses required for the payment of delivery expenses and the lump-sum allowance at childbirth, and other expenses required for national health insurance services borne in the special account of each such Municipality for national health insurance.

From a wide-area or medical specialist perspective, in order to ensure the proper implementation of insurance benefits by the Municipalities within the prefecture and to properly provide subsidies for national health insurance benefit expenses, etc., a prefecture may, as provided by Order of the Ministry of Health, Labour and Welfare, request the Municipalities within that prefecture to provide the claims made by health insurance-covered medical institutions, etc. pursuant to Article 45, paragraph (4) (including as applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3) and Article 53, paragraph (4)), the claims made by designated home-nursing providers pursuant to Article 54-2, paragraph (9) and the claims made by delivery-handling medical institutions providing services covered by health insurance or designated birthing centers pursuant to Article 54-5, paragraph (6) and other information relating to the review and payment of insurance benefits by those Municipalities (including, where a Municipality has entrusted its affairs concerning insurance benefits to a Federation of National Health Insurance Associations or the organization (referred to as a "case of entrustment of affairs" in the following Article), information held by the Federation of National Health Insurance Associations or the organization with respect to the entrusted affairs).

A prefecture may recommend to the Municipality concerned that it cancel all or part of the insurance benefits, if, despite the prefecture having made a request for re-examination, that Municipality does not cancel all or part of the insurance benefits relating to the request for re-examination, and the prefecture finds that those insurance benefits were provided in violation of the provisions of this Act or other relevant laws and regulations, or improperly (excluding where the examination based on the request for re-examination was conducted by the National Health Insurance Medical Fees Review Committee prescribed in Article 87, paragraph (1) (including, where a Federation of National Health Insurance Associations has, pursuant to the provisions of Article 45, paragraph (6), or Article 45, paragraph (6) as applied mutatis mutandis pursuant to Article 54-5, paragraph (7), entrusted affairs concerning the review of medical bills or the review of bills for delivery expenses to a corporation designated by the Minister of Health, Labour and Welfare prescribed in that Article 45, paragraph (6) (hereinafter referred to as a "Designated Association"), the person who conducts the review of those medical bills or the review of those bills for delivery expenses), or by the Review Committee prescribed in Article 19, paragraph (1) of the Act on the Medical Information Infrastructure and Medical Fee Examination and Payment Organization or the special Review Committee prescribed in Article 24, paragraph (1) of that Act).

A Society shall collect insurance premiums from Society members to be allocated to the cost incurred in providing benefits for medical treatment, etc., the expenses required for the payment of delivery expenses and the lump-sum allowance at childbirth, and other expenses for national health insurance services (including expenses incurred in paying young-old payments, etc., old-old aid, etc., the long-term care payment, the contribution for securing medical care in the early phase of an epidemic, etc. and the children and child-rearing support levy and, in the case of a Society set forth in Article 179 of the Health Insurance Act, including expenses incurred in paying day worker contributions under the provisions of the same Act).

amount of revenue subject to fund projects: the amount calculated as provided by Cabinet Order as being applied to the total sum of the amount obtained by deducting the amount equivalent to the co-payment relating to the benefits from the amount of costs spent on benefits for medical treatment by the Municipalities within the prefecture and the amount of costs spent on paying expenses for Dietary Treatment for inpatients, Living Support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, transport expenses, delivery expenses, lump-sum allowance at childbirth, high-cost medical expenses and expenses for high-cost medical treatment combined with long-term care by the Municipalities within the prefecture (referred to as "amount of costs spent on benefits for medical treatment, etc." in the following item), to the amount of expenses incurred in paying the contribution for the special high-cost medical expenses joint project, young-old payments, etc., old-old aid, etc., the long-term care payment, the contribution for securing medical care in the early phase of an epidemic, etc. and the children and child-rearing support levy, to the amount of expenses incurred in making the transfer under the provisions of paragraph (4) and the transfer under the provisions of paragraph (8) (referred to as "financial stabilization fund transfer" in the following item), and to other amounts of expenses specified by Cabinet Order, out of the total of the amounts received during the relevant fiscal year in the special account of the prefecture relating to national health insurance (excluding the amount transferred in pursuant to the provisions of paragraph (2));

information relating to the examination and payment of insurance benefits by the Municipality, such as claims made by health insurance-covered medical institutions, etc. pursuant to the provisions of Article 45, paragraph (4) (including as applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3) and Article 53, paragraph (4)) and, claims made by designated home-nursing providers pursuant to the provisions of Article 54-2, paragraph (9) and claims made by delivery-handling medical institutions providing services covered by health insurance or designated birthing centers pursuant to the provisions of Article 54-5, paragraph (6) (including, where the Municipality has entrusted its affairs relating to insurance benefits to a Federation of National Health Insurance Associations or the organization, information held by the Federation of National Health Insurance Associations or the organization in relation to the entrusted affairs);

A Federation conducts the operations of examination and payment, performed as entrusted by Municipalities and Societies pursuant to the provisions of Article 45, paragraph (5) (including as applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and, Article 54-2, paragraph (12)), , Article 54-5, paragraph (7) and Article 54-11, paragraph (6)), concerning claims for the expenses required for benefits for medical treatment and for expenses for Dietary Treatment for inpatients, expenses for Living Support for inpatients, medical expenses combined with treatment outside insurance coverage and, medical expenses for home-nursing and delivery expenses, and the operations concerning payment of lump-sum allowance at childbirth.

In order to review medical bills as entrusted pursuant to the provisions of Article 45, paragraph (5) or review bills for delivery expenses as entrusted pursuant to the provisions of Article 45, paragraph (5) as applied mutatis mutandis pursuant to Article 54-5, paragraph (7), a Federation whose district covers the area of a prefecture (excluding any such Federation that has not been joined by two-thirds or more of the prefectures or Municipalities, or Societies within its district) shall have a National Health Insurance Medical Fees Review Committee (hereinafter referred to as the "Review Committee").

A Federation may, as far as not hindering the carrying out of the affairs set forth in the preceding paragraph, have the Review Committee conduct the review of medical bills to be conducted as entrusted pursuant to the provisions of Article 76, paragraph (5) of the Health Insurance Act or the review of bills for delivery expenses to be conducted as entrusted pursuant to the provisions of Article 98-2, paragraph (8) of that Act.

When the Review Committee finds it necessary in order to review medical bills or review bills for delivery expenses, it may, upon the approval of the prefectural governor, request the relevant Health Insurance-Covered Medical Institutionhealth insurance-covered medical institution, etc. or, the relevant office providing designated home-nursing home nursing or the relevant designated birthing center to make a report or submit or present medical records , birth records or other books and documents, or may request any of the establishers or administrators of such Health Insurance-Covered Medical Institutionhealth insurance-covered medical institution, etc., the designated home-nursing provider, any of the establishers or administrators of such designated birthing center, any of the health insurance-covered physicians or health insurance-covered pharmacists who are in charge of medical treatment at such Health Insurance-Covered Medical Institutionhealth insurance-covered medical institution, etc., or any of the health insurance-covered physicians (limited to physicians) or registered midwives who are in charge of delivery care at the relevant delivery-handling medical institution providing services covered by health insurance or designated birthing center to appear or provide an explanation.

The Federation must pay travel expenses, daily expenses and accommodation expenses to any person who appeared at the Review Committee pursuant to the provisions of the preceding paragraph; provided, however, that this shall not apply to any person who appeared in response to a request for appearance issued due to defective or misleading entries in medical bills or bills for delivery expenses or medical records , birth records or other books and documents submitted by the relevant Health Insurance-Covered Medical Institutionhealth insurance-covered medical institution, etc. or, the relevant office providing designated home-nursinghome nursing or the relevant designated birthing center.

The Minister of Health, Labour and Welfare, prefectures, Municipalities, Societies, health insurance-covered medical institutions, etc., designated home-nursing providers, designated birthing centers and other persons specified by Order of the Ministry of Health, Labour and Welfare as persons who use the insured person's symbol and number, etc. (meaning insurer numbers (meaning numbers that the Minister of Health, Labour and Welfare sets for each Municipality or Society as numbers for identifying Municipalities or Societies in national health insurance services) and insured person's symbol and number (meaning symbols, numbers and other codes that a Municipality or Society sets for each insured person for managing eligibility as an insured person); hereinafter the same applies in this Article) for the performance of national health insurance services or affairs related to those services (referred to as the "Minister of Health, Labour and Welfare, etc." in this Article) must not, except where necessary for the performance of those services or affairs, request any person to disclose the insured person's symbol and number, etc. relating to that person or a person other than that person.

In addition to the affairs prescribed in Article 45, paragraph (5) (including as applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and, Article 54-2, paragraph (12), Article 54-5, paragraph (7) and Article 54-11, paragraph (6)), an insurer may entrust the following affairs to the Federation prescribed in Article 45, paragraph (5) or the organization:

When the Minister of Health, Labour and Welfare or a prefectural governor finds it necessary in relation to an insurance benefit, said minister or governor may order any physician, dentist , pharmacist or pharmacistmidwife or any person who gave treatment or any person who employs any of the above to make a report or present medical records, birth records, the books and other documents or any other article, or may have personnel question any of the above persons, regarding the medical care or medication or treatment, or delivery care, provided by the relevant person.

When the Minister of Health, Labour and Welfare or the prefectural governor finds it necessary, said minister or governor may order a current or former insured person who received payment of benefits for medical treatment or expenses for Dietary Treatment for inpatients, expenses for Living Support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses for home-nursing or, special medical expenses or delivery expenses to make a report or may have personnel question such insured person, regarding the content of the medical care, preparation of drugs , designated home nursing or designated home-nursingdelivery care relevant to the payment of said benefit for medical treatment or said expenses for Dietary Treatment for inpatients, expenses for Living Support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses for home-nursing or, special medical expenses or delivery expenses.

When the Minister of Health, Labour and Welfare or a prefectural governor conducts any of the affairs specified in Article 41, paragraph (1) (including cases where applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and Article 54-3, paragraph (7)) and paragraph (2) (including cases where applied mutatis mutandis pursuant to Article 45-2, paragraph (4), Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and Article 54-3, paragraph (7)), Article 45-2, paragraph (1) (including cases where applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and Article 54-3, paragraph (7)), Article 54-2-2 (including cases where applied mutatis mutandis pursuant to Article 54-3, paragraph (7)), Article 54-2-3, paragraph (1) (including cases where applied mutatis mutandis pursuant to Article 54-3, paragraph (7)), Article 54-7, paragraph (1), paragraph (2) of that Article (including cases where applied mutatis mutandis pursuant to Article 54-8, paragraph (2)), Article 54-8, paragraph (1) and Article 114 pursuant to these provisions, the relevant affairs shall be conducted under mutually close coordination.

The affairs which shall be handled by a prefecture pursuant to the provisions of Article 17, paragraph (1) and paragraph (3) (including cases where applied mutatis mutandis pursuant to Article 27, paragraph (3)), Articles 24-4 and 24-5, Article 25, paragraph (1), Article 27, paragraphs (2) and (4), Article 32, paragraph (2), Article 32-2, paragraph (2), Article 32-7, paragraph (1) and paragraph (2) (including cases where applied mutatis mutandis pursuant to paragraph (3) of the same Article), Article 32-12, Article 41, paragraph (1) (including cases where applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and Article 54-3, paragraph (7)) and paragraph (2) (including cases where applied mutatis mutandis pursuant to Article 45-2, paragraph (4), Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and Article 54-3, paragraph (7)), Article 45, paragraph (3) and Article 45-2, paragraphs (1) and (5) (including cases where these provisions shall apply mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and Article 54-3, paragraph (7)), Article 54-2-2 and Article 54-2-3, paragraphs (1) and (3) (including cases where these provisions shall apply mutatis mutandis pursuant to Article 54-3, paragraph (7)), Article 54-7, paragraph (1), paragraph (2) of that Article (including cases where applied mutatis mutandis pursuant to Article 54-8, paragraph (2)), Article 54-8, paragraphs (1) and (3), Article 80, paragraph (1), Article 88 and Article 89, paragraph (1), the affairs which shall be handled by a prefecture pursuant to the provisions of Article 106, paragraph (1) (limited to the part relating to item (ii)), Article 107 (limited to the part relating to item (ii)) and Article 108 and which are relevant to a Society, and the affairs which shall be handled by a prefecture pursuant to the provisions of Article 114 shall be Type 1 statutory entrusted functions as prescribed in Article 2, paragraph (9), item (i) of the Local Autonomy Act.

The provisions of the preceding paragraph shall also apply when a person who conducts or used to conduct the review of medical bills as specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 45, paragraph (7) (including cases where applied mutatis mutandis pursuant to Article 52, paragraph (6), Article 52-2, paragraph (3), Article 53, paragraph (4) and Article 54-2, paragraph (12)), a person who conducts the review of bills for delivery expenses as specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 45, paragraph (7) as applied mutatis mutandis pursuant to Article 54-5, paragraph (7), or a person who used to conduct either of those reviews, or a current or former officer or employee of a Designated Association divulges, without a justifiable reason, any confidential information obtained in the course of said person's duties.

When a physician, dentist , pharmacist or pharmacistmidwife or any person who gave treatment or any person who employs any of the above fails, without a justifiable reason, to comply with an order to make a report or present medical records, birth records, the books and other documents or any other article issued pursuant to the provisions of Article 114, paragraph (1) or, without a justifiable reason, fails to reply, or makes a false reply, to any question asked by the relevant personnel pursuant to the provisions of the same paragraph of the same Article, said person shall be punished by a non-criminal fine of not more than 100,000 yen.