National Health Insurance Act

Municipalities and Societies shall pay benefits for the types of medical treatment listed in the following items with respect to an insured person's illness and injury; provided, however, that this shall not apply during any period in which the Householder or Society member of the household to which such insured person belongs is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to such insured person:

medical examinations;

provision of medication or materials for medical treatment;

treatment, operations or any other medical treatment;

in-home medical care management as well as caretaking and any other nursing involved in in-home medical care;

hospitalization or visiting a clinic, and caretaking and other nursing incidental to medical treatment provided there.

Benefits for the following types of medical treatment shall not be included in the benefits set forth in the preceding paragraph:

medical treatment which consists of the provision of meals and is given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (excluding hospitalization in a sanatorium ward as set forth in Article 7, paragraph (2), item (iv) of the Medical Treatment Act (Act No. 205 of 1948) and care and other nursing incidental to the medical treatment there which is provided to an insured person whose 65th birthday is on any month before the month in which said person receives the relevant medical treatment (hereinafter referred to as a "Person Specified as Hospitalized Long-term and Insured")) (hereinafter referred to as "Dietary Treatment");

the following types of medical treatment given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (limited to medical treatment provided to a Person Specified as Hospitalized Long-term and Insured; hereinafter referred to as "Living Support"):

medical treatment consisting of the provision of meals;

medical treatment consisting of the creation of an appropriate environment for medical treatment in terms of temperature, lighting and water supply;

evaluation treatment (meaning the evaluation treatment as set forth in Article 63, paragraph (2), item (iii) of the Health Insurance Act; hereinafter the same shall apply);

patient-requested treatment (meaning the patient-requested treatment as set forth in Article 63, paragraph (2), item (iv) of the Health Insurance Act; hereinafter the same shall apply);

selective treatment (meaning the selective treatment as set forth in Article 63, paragraph (2), item (v) of the Health Insurance Act; hereinafter the same shall apply).

treatment partially outside insurance coverage (meaning the treatment partially outside insurance coverage as set forth in Article 63, paragraph (2), item (vi) of the Health Insurance Act; hereinafter the same shall apply).

When an insured person seeks to receive the benefits set forth in paragraph (1), the insured person is to receive confirmation of being an insured person from the Health Insurance-Covered Medical Institution, etc. of the insured person's choice (meaning a Health Insurance-Covered Medical Institution (meaning the Health Insurance-Covered Medical Institution prescribed in Article 63, paragraph (3), item (i) of the Health Insurance Act; hereinafter the same applies) or the health insurance-covered pharmacy prescribed in that item; hereinafter the same applies) by electronic eligibility confirmation (meaning that a person seeking to receive medical treatment from a Health Insurance-Covered Medical Institution, etc., a person seeking to receive designated home nursing prescribed in Article 54-2, paragraph (1) from a designated home-nursing provider prescribed in that paragraph, or a person seeking to receive delivery care from a delivery-handling medical institution providing services covered by health insurance (meaning the delivery-handling medical institution providing services covered by health insurance prescribed in Article 58, paragraph (3) of the Health Insurance Act; hereinafter the same applies) or a designated birthing center (meaning the designated birthing center prescribed in Article 98-2, paragraph (1), item (i) of the Health Insurance Act; hereinafter the same applies), makes an inquiry to a Municipality or Society about information pertaining to eligibility as an insured person (including information necessary for claims for expenses pertaining to insurance benefits) by a method of transmitting an electronic certificate for user verification (meaning the electronic certificate for user verification prescribed in Article 22, paragraph (1) of the Act on Certification Business of the Japan Agency for Local Authority Information Systems in Relation to Electronic Signatures, etc. (Act No. 153 of 2002)) recorded on an Individual Number Card (meaning the Individual Number Card prescribed in Article 2, paragraph (7) of the Act on the Use of Numbers to Identify a Specific Individual in Administrative Procedures (Act No. 27 of 2013)) or by any other method specified by Order of the Ministry of Health, Labour and Welfare, receives a response from the Municipality or Society by a method using an electronic data processing system or other method using information and communications technology, provides that information to the Health Insurance-Covered Medical Institution, etc., designated home-nursing provider, or delivery-handling medical institution providing services covered by health insurance or designated birthing center, and receives confirmation of being an insured person from that Health Insurance-Covered Medical Institution, etc., designated home-nursing provider, or delivery-handling medical institution providing services covered by health insurance or designated birthing center; hereinafter the same applies) or by any other method specified by Order of the Ministry of Health, Labour and Welfare (hereinafter referred to as "electronic eligibility confirmation, etc."), and then to receive the benefits set forth in paragraph (1); provided, however, that this confirmation is not required if the case falls under a case specified by Order of the Ministry of Health, Labour and Welfare.

The rules applicable in cases where a health insurance-covered medical institution, etc. or a health insurance-covered physician or health insurance-covered pharmacist (meaning the health insurance-covered physician or health insurance-covered pharmacist as set forth in Article 64 of the Health Insurance Act; hereinafter the same shall apply) shall be in charge of benefits for medical treatment under a national health insurance program or shall provide medical care or prescription service under a national health insurance program, shall be governed by the same rules as those in the Order of the Ministry of Health, Labour and Welfare under Article 70, paragraph (1) and Article 72, paragraph (1) of that Act.

In the case referred to in the preceding paragraph, when it is difficult or is not found appropriate for Ordinance of Ministry of Health, Labour and Welfare set forth in the same paragraph to govern such rules, said rules shall be prescribed by another Ordinance of the Ministry of Health, Labour and Welfare.

Guidance by the Minister of Health, Labour and Welfare or the prefectural governor must be received by Health Insurance-Covered Medical Institutions, etc. with respect to benefits for medical treatment and by health insurance-covered physicians and health insurance-covered pharmacists with respect to medical care or prescription service provided under a national health insurance program.

In cases where the guidance set forth in the preceding paragraph is provided, the Minister of Health, Labour and Welfare or the prefectural governor shall, when finding it necessary, have a person(s) with knowledge and experience of medical care or prescription service attend such guidance in accordance with the designation by concerned organizations; provided, however, that this shall not apply where such concerned organizations make no such designation or where the person(s) so designated fail to attend.

A person who receives benefit for medical treatment in relation to an Health Insurance-Covered Medical Institution, etc. pursuant to the provisions of Article 36, paragraph (3) shall pay, in accordance with the categories listed in the following items, an amount obtained by multiplying the amount calculated pursuant to the provisions of Article 45, paragraph (2) or (3) with respect to such benefit by the ratio listed in the relevant item below, as said person's co-payment to such Health Insurance-Covered Medical Institution, etc. when receiving such benefit:

in cases where the first March 31 after said person's 6th birthday has passed and the month in which said person's 70th birthday is has not yet started:0.3;

in cases where the first March 31 after said person's 6th birthday has not yet passed:0.2;

in cases where the month in which said person's 70th birthday is has elapsed (excluding the case listed in the following item):0.2;

in cases where the month in which said person's 70th birthday is has elapsed and where the amount of income calculated pursuant to Cabinet Order provisions with respect to the insured persons (limited to persons whose 70th birthday is in any month before the current month and other persons specified by Cabinet Order) who belong to the household to which the person who receives such benefit for medical treatment belongs is not less than the amount specified by Cabinet Order:0.3.

A health insurance-covered medical institution, etc. shall receive the co-payment set forth in the preceding paragraph (or, when the ratio of co-payment is reduced pursuant to the provisions of Article 43, paragraph (1), the co-payment calculated in accordance with the ratio after such reduction in the case of a health insurance-covered medical institution, etc. set forth in paragraph (2) of the same Article or, when the measure set forth in Article 44, paragraph (1), item (i) is taken, the co-payment after the relevant reduction) and, when an insured person fails to make all or part of such co-payment despite efforts of the health insurance-covered medical institution, etc. to receive such payment with the same care as due care of a prudent manager, Municipalities and Societies may impose a disposition on such insured person pursuant to the same rules as those for the monies to be collected pursuant to the provisions of this Act, at the request of such health insurance-covered medical institution, etc.

In cases where co-payment shall be made pursuant to the provisions of paragraph (1) of the preceding Article, any fraction of less than five yen in the amount of co-payment set forth in the same paragraph shall be rounded down to the nearest ten yen, whereas any fraction of more than five yen and less than ten yen shall be rounded up to the nearest ten yen.

Municipalities and Societies may, pursuant to Cabinet Order provisions, reduce the ratio of co-payment set forth in Article 42, paragraph (1) by Municipal Ordinance or by constitution.

When the ratio of co-payment is reduced pursuant to the provisions of the preceding paragraph, it shall be sufficient for an insured person who receives benefits for medical treatment in relation to one of the health insurance-covered medical institutions, etc. designated by a Municipality or Society with the consent of their respective establishers, to pay co-payment calculated in accordance with the ratio after such reduction to such health insurance-covered medical institution, etc., notwithstanding the provisions of Article 42, paragraph (1).

In cases where the ratio of co-payment has been reduced pursuant to the provisions of paragraph (1) and when an insured person has received benefits for medical treatment at or from a health insurance-covered medical institution, etc. which is not one of those set forth in the preceding paragraph, Municipalities and Societies must pay to such insured person the difference between the amount of co-payment paid by such insured person to the health insurance-covered medical institution, etc. pursuant to the provisions of Article 42, paragraph (1) and the amount of co-payment calculated pursuant to the ratio after the reduction made pursuant to the provisions of paragraph (1).

The provisions of the preceding Article shall apply mutatis mutandis to the making of co-payment in the case set forth in paragraph (2).

Municipalities and Societies may take any of the measures listed in the following items with respect to any insured person who is under special circumstances and for whom it is found difficult to make co-payment to a health insurance-covered medical institution, etc. pursuant to the provisions of Article 42 or the preceding Article:

to reduce the amount of co-payment;

to exempt such insured person from making co-payment;

to decide to collect co-payment directly from such insured person in lieu of co-payment to the Health Insurance-Covered Medical Institution, etc., and to suspend such collection.

Notwithstanding the provisions of paragraph (1) of Article 42 and paragraph (2) of the preceding Article, where the measure set forth in item (i) of the preceding paragraph has been taken with respect to an insured person, it shall be sufficient for said person to pay the amount of co-payment so reduced to the relevant Health Insurance-Covered Medical Institution, etc., and where the measure set forth in item (ii) or (iii) has been taken with respect to an insured person, said person shall not be required to make co-payment to the relevant Health Insurance-Covered Medical Institution, etc.

The provisions of Article 42-2 shall apply mutatis mutandis to the making of co-payment in the case set forth in the preceding paragraph.