National Health Insurance Act

Guidance by the Minister of Health, Labour and Welfare or prefectural governors must be received by each designated home-nursing provider and nurses and other employees at the office relevant to its designation with respect to designated home-nursing.

When the Minister of Health, Labour and Welfare or a prefectural governor finds it necessary in relation to the payment of medical expenses for home-nursing, said minister or governor may order a designated home-nursing provider or an entity which was a designated home-nursing provider or any of the persons who were nurses or other employees at the office relevant to such designation (hereinafter referred to as a "Former Designated Home-nursing Business, etc." in this paragraph) to make a report or submit or present the books and other documents, may request a designated home-nursing provider or nurses or other employees at the office relevant to its designation (including Former Designated Home-nursing Businesses, etc.) to appear, or may have personnel question persons involved or inspect the books and other documents or other articles of such designated home-nursing provider at the office relevant to its designation.

The provisions of Article 45-2, paragraph (2) shall apply mutatis mutandis to questions asked or inspections conducted pursuant to the provisions of the preceding paragraph, and the provisions of paragraph (3) of the same Article shall apply mutatis mutandis to the authority under the provisions of the preceding paragraph.

When a prefectural governor finds it necessary that a disposition be made pursuant to the provisions of Article 95 of the Health Insurance Act with respect to a designated home-nursing provider in relation to designated home-nursing provided under this Act, said governor must notify the Minister of Health, Labour and Welfare thereof, together with the reason therefor.

In the case where a Householder who is in arrears with insurance premiums (limited to a Householder who has a domicile within the area of the Municipality) or a Society member who is in arrears with insurance premiums (excluding a Householder or Society member all of whose insured persons belonging to the household are able to receive payment of general medical expenses under the Atomic Bomb Survivors' Assistance Act (Act No. 117 of 1994) or other benefits relating to medical care specified by Order of the Ministry of Health, Labour and Welfare (referred to as "payment of general medical expenses for atomic bomb survivors, etc." in this paragraph and paragraph (5)); hereinafter referred to as a "householder, etc. in arrears with insurance premiums" in this Article) still does not pay those insurance premiums during the period until the period specified by Order of the Ministry of Health, Labour and Welfare has elapsed from the due date for payment of those insurance premiums even though the Municipality or Society concerned has taken measures contributing to payment of insurance premiums specified by Order of the Ministry of Health, Labour and Welfare, such as encouraging payment of those insurance premiums and ensuring opportunities for consultation on payment of those insurance premiums (referred to as "encouragement of insurance premium payment, etc." in the following paragraph and Article 63-2, paragraphs (1) and (2)), then, except where it is found that there are special circumstances specified by Cabinet Order, such as a disaster, in the arrears of those insurance premiums, when an insured person belonging to that household (excluding persons able to receive payment of general medical expenses for atomic bomb survivors, etc. and persons in the period until the first March 31 on or after the day on which they reach the age of 18; the same applies hereinafter in this Article (excluding paragraphs (5) and (6))) receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider, Municipalities and Societies are to pay special medical expenses to the householder, etc. in arrears with insurance premiums with respect to the expenses incurred in that medical treatment or designated home nursing, in lieu of benefits for medical treatment or payment of expenses for Dietary Treatment for inpatients, etc. (meaning expenses for Dietary Treatment for inpatients, Living Support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses or medical expenses for home-nursing; the same applies in paragraphs (5) and (6)) (referred to as "Benefits for Medical Treatment, etc." in the following paragraph and paragraph (6)).

Even before the period specified by Order of the Ministry of Health, Labour and Welfare prescribed in the preceding paragraph has elapsed, in the case where a householder, etc. in arrears with insurance premiums still does not pay the insurance premiums even though the Municipality or Society concerned has carried out encouragement of insurance premium payment, etc., when an insured person belonging to the household receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider, Municipalities and Societies may pay special medical expenses to that householder, etc. in arrears with insurance premiums with respect to the expenses incurred in that medical treatment or designated home nursing, in lieu of Benefits for Medical Treatment, etc.; provided, however, that this does not apply when it is found that there are special circumstances specified by Cabinet Order in that paragraph.

When paying special medical expenses pursuant to the provisions of paragraph (1) or the main clause of the preceding paragraph, Municipalities and Societies are to notify in advance the householder, etc. in arrears with insurance premiums, as provided by Order of the Ministry of Health, Labour and Welfare, that special medical expenses will be paid when an insured person belonging to the household receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider.

The amount of special medical expenses shall be the amount specified in item (i) (or the total sum 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 obtained by deducting, with respect to such medical treatment (excluding Dietary Treatment and Living Support), from the amount specified in the one of (a) through (d) below that applies to the relevant case, the amount obtained by multiplying that amount 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);

in cases where benefits for medical treatment can be received: the amount of expenses calculated in accordance with the rules prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 76, paragraph (2) 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);

in cases prescribed in Article 53, paragraph (2) where payment of medical expenses combined with treatment outside insurance coverage can be received: the amount of expenses calculated 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);

in cases prescribed in Article 53, paragraph (3) where payment of medical expenses combined with treatment outside insurance coverage can be received: the amount calculated by deducting, from the amount of expenses calculated 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;

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

the amount calculated by deducting the amount of Standard Living Expense Co-payment from the amount of expenses calculated for such Living Support in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of 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 a householder, etc. in arrears with insurance premiums who is subject to the application of paragraph (1) or the main clause of paragraph (2) has paid the arrears of insurance premiums in full, or where it is found that there are special circumstances specified by Cabinet Order, such as a significant decrease in the amount in arrears pertaining to that person or a disaster, or where an insured person belonging to that household has become a person able to receive payment of general medical expenses for atomic bomb survivors, etc., when an insured person belonging to the household of the Householder or Society member who falls under these cases (in the case where an insured person belonging to the household of that householder, etc. in arrears with insurance premiums has become a person able to receive payment of general medical expenses for atomic bomb survivors, etc., limited to that insured person; the same applies hereinafter in this paragraph and the following paragraph) receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider, Municipalities and Societies are to provide benefits for medical treatment to the insured person belonging to the household of that Householder or Society member, or pay expenses for Dietary Treatment for inpatients, etc. to that Householder or Society member.

When providing benefits for medical treatment or paying expenses for Dietary Treatment for inpatients, etc. pursuant to the provisions of the preceding paragraph, Municipalities and Societies are to notify in advance the Householder or Society member who falls under the case prescribed in that paragraph, as provided by Order of the Ministry of Health, Labour and Welfare, that Benefits for Medical Treatment, etc. will be provided when an insured person belonging to the household receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider.

The provisions of paragraph (3) of Article 36, Articles 40 and 41, paragraph (3) of Article 45, Article 45-2, paragraph (5) of Article 52, paragraphs (3), (8) and (10) of Article 54-2, Article 54-2-2 and the preceding Article of this Act, and Article 64 of the Health Insurance Act shall apply mutatis mutandis to medical treatment or designated home nursing covered by special medical expenses received at or from a health insurance-covered medical institution, etc. or a designated home-nursing provider and to the payment of special medical expenses associated with such medical treatment or designated home nursing. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.

When the provisions of Article 54, paragraph (1) would apply to an insured person belonging to the household of a householder, etc. in arrears with insurance premiums who is subject to the application of paragraph (1) or the main clause of paragraph (2) if the insured person were not subject to the application of those provisions, Municipalities and Societies may pay medical expenses.

Where an insured person belonging to the household of a householder, etc. in arrears with insurance premiums who is subject to the application of paragraph (1) or the main clause of paragraph (2) 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 it is found that the failure to receive such confirmation was due to an emergency situation or any other unavoidable reason, Municipalities and Societies shall pay medical expenses.

The provisions of Article 54, paragraphs (3) and (4) shall apply mutatis mutandis to the medical expenses under the preceding two paragraphs. In this case, the phrase "shall be received" in paragraph (4) of that Article shall be deemed to be replaced with "can be received".

When an insured person has been transported to a hospital or clinic in order to receive benefits for medical treatment (including medical treatment covered by medical expenses combined with treatment outside insurance coverage and medical treatment covered by special medical expenses), Municipalities and Societies shall pay, as transport expenses, an amount calculated as provided by Order of the Ministry of Health, Labour and Welfare to the Householder or Society member of the household to which said insured person belongs.

The transport expenses 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.