National Health Insurance Act

When an insured person has received evaluation treatment, patient-requested treatment, selective treatment or treatment partially outside insurance coverage at or from a health insurance-covered medical institution, etc. of said person's choice, Municipalities and Societies shall pay medical expenses combined with treatment outside insurance coverage to the Householder or Society member of the household to which said insured person belongs with respect to the expenses incurred in that treatment; 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.

In the case where evaluation treatment, patient-requested treatment or selective treatment has been received (excluding the case where treatment partially outside insurance coverage has been received together with that evaluation treatment, patient-requested treatment or selective treatment), the amount of medical expenses combined with treatment outside insurance coverage shall be the amount specified in item (i) (or the aggregate of such amount and the amount specified in item (ii) or (iii) when such medical treatment includes Dietary Treatment and Living Support, respectively):

the amount calculated by deducting, from the amount of expenses calculated for such medical treatment (excluding Dietary Treatment and Living Support) in accordance with the rules prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 86, paragraph (2), item (i) of the Health Insurance Act (or, when said amount exceeds the amount of expenses actually incurred in such medical treatment, such amount of expenses actually incurred in such medical treatment), the amount obtained by multiplying such amount by the applicable ratio listed in the items of paragraph (1) of Article 42, in accordance with the categories listed in the items of the same paragraph (or, where the ratio for co-payment has been reduced pursuant to the provisions of Article 43, paragraph (1), the ratio after such reduction) (or, if any of the measures listed in the items of paragraph (1) of Article 44 needs to be taken with respect to the co-payment set forth in Article 42, paragraph (1) for benefits for medical treatment, the amount calculated as if the relevant measures were taken);

the amount calculated by deducting the amount of Standard Co-payment for Dietary Treatment from the amount calculated for such Dietary Treatment in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the Article 85, paragraph (2) of the Health Insurance Act (or, when said amount exceeds the amount of expenses actually incurred for such Dietary Treatment, such amount of expenses actually incurred for such Dietary Treatment);

the amount calculated by deducting the amount of Standard Co-payment for Living Support from the amount calculated for such Living Support in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the Article 85-2, paragraph (2) of the Health Insurance Act (or, when said amount exceeds the amount of expenses actually incurred in such Living Support, such amount of expenses actually incurred in such Living Support).

In the case where treatment partially outside insurance coverage has been received (including the case where evaluation treatment, patient-requested treatment or selective treatment has been received together with that treatment partially outside insurance coverage), the amount of medical expenses combined with treatment outside insurance coverage shall be the amount obtained by deducting the amount specified in item (ii) from the amount specified in item (i) (or the aggregate of the amount so deducted and the amount specified in item (ii) of the preceding paragraph when such medical treatment includes Dietary Treatment, or the aggregate of the amount so deducted and the amount specified in item (iii) of that paragraph when such medical treatment includes Living Support):

the amount calculated by deducting, from the amount of expenses calculated for such medical treatment (excluding Dietary Treatment and Living Support) in accordance with the rules prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 86, paragraph (3), item (i), (a) of the Health Insurance Act (or, when said amount exceeds the amount of expenses actually incurred in such medical treatment, such amount of expenses actually incurred in such medical treatment), the amount calculated in accordance with the rules prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of (b) of that item;

the amount obtained by multiplying the amount specified in the preceding item by the ratio listed in the items of Article 42, paragraph (1), in accordance with the categories listed in the items of that paragraph (or, where the ratio of co-payment has been reduced pursuant to the provisions of Article 43, paragraph (1), the ratio after such reduction) (or, if any of the measures listed in the items of Article 44, paragraph (1) needs to be taken with respect to the co-payment set forth in Article 42, paragraph (1) for benefits for medical treatment, the amount calculated as if those measures were taken).

The provisions of 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 Article 52 of this Act, and Article 64 of the Health Insurance Act shall apply mutatis mutandis to evaluation treatment, patient-requested treatment, selective treatment and treatment partially outside insurance coverage received at or from a health insurance-covered medical institution, etc. and to the payment of medical expenses combined with treatment outside insurance coverage associated with such treatment. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.

The provisions of Article 42-2 shall apply mutatis mutandis to the payment of the amount calculated by deducting the amount payable as medical expenses combined with treatment outside insurance coverage with respect to expenses incurred in the relevant medical treatment from the amount of expenses calculated for such medical treatment pursuant to the provisions of paragraph (2) or (3) in the case set forth in Article 52, paragraph (3) as applied mutatis mutandis pursuant to the preceding paragraph (or, when said amount exceeds the amount of expenses actually incurred in such medical treatment, said amount of expenses actually incurred in such medical treatment).

Municipalities and Societies, when they find it difficult to pay benefits for medical treatment or expenses for Dietary Treatment for inpatients, Living Support expenses for inpatients or medical expenses combined with treatment outside insurance coverage (hereinafter referred to as "Benefits for Medical Treatment, etc." in this paragraph and the following paragraph), or when, in cases where an insured person has received any medical care, medication or treatment at or from a hospital, clinic, pharmacy or any other person other than a health insurance-covered medical institution, etc., a Municipality or Society finds it unavoidable, may pay medical expenses in lieu of Benefits for Medical Treatment, etc.; provided, however, that this shall not apply during any period in which the Householder or Society member of the household to which said insured person belongs is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to said insured person.

Where an insured person has received any medical care or medication at or from a health insurance-covered medical institution, etc. without receiving confirmation of being an insured person by electronic eligibility confirmation, etc., and when Municipalities and Societies find that the failure to receive such confirmation was due to an emergency or any other unavoidable reason, they shall pay medical expenses in lieu of Benefits for Medical Treatment, etc.; provided, however, that this shall not apply during any period in which the Householder or Society member of the household to which said insured person belongs 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 amount of medical expenses shall be determined by the Municipality or Society based on the amount calculated by deducting, from the amount calculated for such medical treatment (excluding Dietary Treatment and Living Support) (or, in the case where treatment partially outside insurance coverage has been received (including the case where evaluation treatment, patient-requested treatment or selective treatment has been received together with that treatment partially outside insurance coverage), the amount obtained by deducting from that amount the amount calculated in accordance with the precedent of the determination by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 86, paragraph (3), item (i), (b) of the Health Insurance Act), the amount calculated by multiplying such amount by the applicable ratio listed in the items of paragraph (1) of Article 42, in accordance with the categories listed in the items of the same paragraph, and the amount calculated by deducting, from the amount of expenses calculated for such Dietary Treatment or Living Support, the amount of Standard Co-payment for Dietary Treatment or Standard Living Expense Co-payment, respectively.

In calculating the amount of expenses set forth in the preceding paragraph, the provisions of Article 45, paragraph (2) shall apply mutatis mutandis to cases where benefit for medical treatment shall be received, those of Article 52, paragraph (2) shall apply mutatis mutandis to cases where expenses for Dietary Treatment for inpatients shall be received, those of Article 52-2, paragraph (2) shall apply mutatis mutandis to cases where expenses for Living Support for inpatients shall be received, and those of paragraph (2) or (3) of the preceding Article shall apply mutatis mutandis to cases where medical expenses combined with treatment outside insurance coverage shall be received; provided, however, that such amount shall not exceed the amount of expenses actually incurred in the relevant medical treatment.

When an insured person has received, at or from a designated home-nursing provider (meaning the designated home-nursing provider as set forth in Article 88, paragraph (1) of the Health Insurance Act; hereinafter the same shall apply), designated home nursing (meaning the designated home nursing as set forth in that paragraph; hereinafter the same shall apply), Municipalities and Societies shall pay medical expenses for home-nursing to the Householder or Society member of the household to which said insured person belongs with respect to expenses incurred in such designated home nursing; 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 medical expenses for home-nursing set forth in the preceding paragraph shall be paid only if a Municipality or Society finds it necessary, as provided by Order of the Ministry of Health, Labour and Welfare.

When an insured person seeks to receive designated home nursing, the insured person is to, as provided by Order of the Ministry of Health, Labour and Welfare, receive confirmation of being an insured person from the designated home-nursing provider of the insured person's choice by electronic eligibility confirmation, etc., and receive that designated home nursing.

The amount of medical expenses for home-nursing shall be calculated by deducting, from the amount calculated for such designated home-nursing in accordance with the rules prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 88, paragraph (4) of the Health Insurance Act, the amount calculated by multiplying such amount by the applicable ratio listed in the items of paragraph (1) of Article 42, in accordance with the categories listed in the items of the same paragraph (or, when the ratio for co-payment has been reduced pursuant to the provisions of Article 43, paragraph (1), the ratio after such reduction) (or, when any of the measures listed in the items of paragraph (1) of Article 44 needs be taken with respect to the co-payment set forth in Article 42, paragraph (1) for benefits for the medical treatment, the amount calculated as if the relevant measures were taken).

When an insured person has received designated home nursing at or from a designated home-nursing provider, Municipalities and Societies may, on behalf of the Householder or Society member of the household to which said insured person belongs, pay to said designated home-nursing provider expenses incurred in said designated home nursing that are payable by that Householder or Society member to said designated home-nursing provider, within the limit of the amount payable to that Householder or Society member as medical expenses for home-nursing.

When a payment is made pursuant to the provisions of the preceding paragraph, the Householder or Society member shall be deemed to have received medical expenses for home-nursing.

The provisions of Article 42-2 shall apply mutatis mutandis to the payment of the amount calculated by deducting, from the amount of expenses calculated pursuant to the provisions of paragraph (4) in the case set forth in paragraph (5), the amount payable as medical expenses for home-nursing with respect to expenses incurred in the relevant designated home-nursing.

Upon acceptance of the payment of expenses incurred in designated home-nursing, the designated home-nursing provider 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.

Upon receipt of a claim by a designated home-nursing provider for medical expenses for home-nursing, Municipalities and Societies shall make payment after conducting an examination according to the method for calculating the amount set forth in paragraph (4) and the rules set forth in the following paragraph.

The rules for cases where a designated home-nursing provider provides designated home-nursing under a national health insurance program shall be governed by the standards for the operation of a designated home-nursing provider prescribed in Article 92, paragraph (2) of the Health Insurance Act (limited to the provisions concerning the handling of designated home-nursing) and, when it is difficult or is not found appropriate for said standards to govern such rules, said rules shall be prescribed by Ordinance of the Ministry of Health, Labour and Welfare.

No designated home-nursing shall be included in any of the types of medical treatment listed in the items of paragraph (1) of Article 36.

The provisions of paragraph (3) of Article 92 of the Health Insurance Act and paragraphs (5) through (8) of Article 45 of this Act shall apply mutatis mutandis to designated home-nursing received at or from a designated home-nursing provider and the payment of medical expenses for home-nursing associated with such service. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.