Article 55Cases Where an Insured Person Has Become a Day Worker or a Dependent Thereof
第五十五条(被保険者が日雇労働者又はその被扶養者となつた場合)
In cases where an insured person has lost eligibility as such as a result of falling under Article 6, item (vii) and where, at the time of loss of such eligibility, said person actually receives benefits for medical treatment, any medical treatment covered by expenses for Dietary Treatment for inpatients, any medical treatment covered by expenses for Living Support for inpatients, any medical treatment covered by medical expenses combined with treatment outside insurance coverage, any medical treatment covered by medical expenses for home-nursing or any medical treatment covered by special medical expenses, or any Designated In-Home Service covered by expenses for In-Home Long-Term Care Service pursuant to the provisions of the Long-Term Care Insurance Act (Act No. 123 of 1997) (meaning the Designated In-Home Service as set forth in Article 41, paragraph (1) of the same Act) (limited to any such service equivalent to medical treatment), any In-Home Service covered by an Exceptional Allowance for In-Home Long-Term Care Service (meaning the In-Home Service as set forth in Article 8, paragraph (1) of the same Act) or any service equivalent thereto (of these services, limited to those equivalent to medical treatment), any Designated Community-Based Service covered by expenses for Community-Based Long-Term Care Service (meaning the Designated Community-Based Service as set forth in Article 42-2, paragraph (1) of the same Act) (limited to any such service equivalent to medical treatment), any Community-Based Service covered by an Exceptional Allowance for Community-Based Long-Term Care Service (meaning the Community-Based Service as set forth in Article 8, paragraph (14) of the same Act) or any service equivalent thereto (of these services, limited to those equivalent to medical treatment), any Designated Facility Service, etc. covered by expenses for Long-Term Care Facility Service (meaning the Designated Facility Service, etc. as set forth in Article 48, paragraph (1) of the same Act) (limited to any such service equivalent to medical treatment), any Facility Service covered by an Exceptional Allowance for Long-Term Care Facility Service (meaning the Facility Service as set forth in Article 8, paragraph (26) of the same Act) (limited to any such service equivalent to medical treatment), any Designated Preventive Service of Long-Term Care covered by expenses for Preventive Service of Long-Term Care (meaning the Designated Preventive Service of Long-Term Care as set forth in Article 53, paragraph (1) of the same Act) (limited to any such service equivalent to medical treatment), or any Preventive Long-Term Care Service covered by an Exceptional Allowance for Preventive Service of Long-Term Care (meaning the Preventive Long-Term Care Service as set forth in Article 8-2, paragraph (1) of the same Act) or any service equivalent thereto (of these services, limited to those equivalent to medical treatment), then such person may receive from that Municipality or Society benefits for medical treatment, 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, special medical expenses or transportation expenses with respect to the relevant illness or injury and any illness arising therefrom.
被保険者が第六条第七号に該当するに至つたためその資格を喪失した場合において、その資格を喪失した際現に療養の給付、入院時食事療養費に係る療養、入院時生活療養費に係る療養、保険外併用療養費に係る療養、訪問看護療養費に係る療養若しくは特別療養費に係る療養又は介護保険法(平成九年法律第百二十三号)の規定による居宅介護サービス費に係る指定居宅サービス(同法第四十一条第一項に規定する指定居宅サービスをいう。)(療養に相当するものに限る。)、特例居宅介護サービス費に係る居宅サービス(同法第八条第一項に規定する居宅サービスをいう。)若しくはこれに相当するサービス(これらのサービスのうち療養に相当するものに限る。)、地域密着型介護サービス費に係る指定地域密着型サービス(同法第四十二条の二第一項に規定する指定地域密着型サービスをいう。)(療養に相当するものに限る。)、特例地域密着型介護サービス費に係る地域密着型サービス(同法第八条第十四項に規定する地域密着型サービスをいう。)若しくはこれに相当するサービス(これらのサービスのうち療養に相当するものに限る。)、施設介護サービス費に係る指定施設サービス等(同法第四十八条第一項に規定する指定施設サービス等をいう。)(療養に相当するものに限る。)、特例施設介護サービス費に係る施設サービス(同法第八条第二十六項に規定する施設サービスをいう。)(療養に相当するものに限る。)、介護予防サービス費に係る指定介護予防サービス(同法第五十三条第一項に規定する指定介護予防サービスをいう。)(療養に相当するものに限る。)若しくは特例介護予防サービス費に係る介護予防サービス(同法第八条の二第一項に規定する介護予防サービスをいう。)若しくはこれに相当するサービス(これらのサービスのうち療養に相当するものに限る。)を受けていたときは、その者は、当該疾病又は負傷及びこれによつて発した疾病について当該市町村又は組合から療養の給付、入院時食事療養費の支給、入院時生活療養費の支給、保険外併用療養費の支給、訪問看護療養費の支給、特別療養費の支給又は移送費の支給を受けることができる。
Payment of benefits for medical treatment, 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, special medical expenses or transportation expenses under the provisions of the preceding paragraph shall not be made when any of the events listed in the following items has occurred:
前項の規定による療養の給付、入院時食事療養費の支給、入院時生活療養費の支給、保険外併用療養費の支給、訪問看護療養費の支給、特別療養費の支給又は移送費の支給は、次の各号のいずれかに該当するに至つたときは、行わない。
when the relevant person has become eligible for payment of benefits for medical treatment, 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, transport expenses, dependent medical expenses, dependent medical expenses for home-nursing or dependent transport expenses pursuant to the provisions of Chapter V of the Health Insurance Act with respect to the relevant illness or injury;
当該疾病又は負傷につき、健康保険法第五章の規定による療養の給付、入院時食事療養費の支給、入院時生活療養費の支給、保険外併用療養費の支給、訪問看護療養費の支給、移送費の支給、家族療養費の支給、家族訪問看護療養費の支給又は家族移送費の支給を受けることができるに至つたとき。
when the relevant person has fallen under any of items (i) through (vi) or items (viii), (ix) or (xi) of Article 6;
その者が、第六条第一号から第六号まで、第八号、第九号又は第十一号のいずれかに該当するに至つたとき。
when that person has come to be able to receive, with respect to that illness or injury, benefits for medical treatment, 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, special medical expenses or transportation expenses from another Municipality or Society;
その者が、当該疾病又は負傷につき、他の市町村又は組合から療養の給付、入院時食事療養費の支給、入院時生活療養費の支給、保険外併用療養費の支給、訪問看護療養費の支給、特別療養費の支給又は移送費の支給を受けることができるに至つたとき。
when six months have elapsed since the day on which the relevant person lost eligibility as an insured person.
被保険者の資格を喪失した日から起算して六箇月を経過したとき。
Payment of benefits for medical treatment, 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, special medical expenses or transportation expenses under the provisions of paragraph (1) shall not be made during any period in which the relevant person is eligible for payment of a special medical expenses or transport expenses or dependent transport expenses pursuant to the provisions of Chapter V of the Health Insurance Act with respect to the relevant illness or injury.
第一項の規定による療養の給付、入院時食事療養費の支給、入院時生活療養費の支給、保険外併用療養費の支給、訪問看護療養費の支給、特別療養費の支給又は移送費の支給は、当該疾病又は負傷につき、健康保険法第五章の規定による特別療養費の支給又は移送費の支給若しくは家族移送費の支給を受けることができる間は、行わない。
Payment of benefits for medical treatment, 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 a special medical expenses under the provisions of paragraph (1) shall not be made in cases where the relevant person is eligible for any benefit corresponding to each of the above benefits pursuant to the provisions of the Long-Term Care Insurance Act with respect to the relevant illness or injury.
第五十六条(他の法令による医療に関する給付との調整)
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, special medical expenses or transportation expenses shall not be made in cases where the insured person is eligible for any benefit relating to medical services pursuant to the provisions of the Health Insurance Act, the Mariners Insurance Act, the National Public Officers Mutual Aid Association Act (including cases where applied mutatis mutandis pursuant to other Acts or where the same rule governs), the Local Public Officers, etc. Mutual Aid Association Act or the Act on Assurance of Medical Care for Elderly People or where said person is eligible for any benefit corresponding to each of the above benefits pursuant to the provisions of the Long-Term Care Insurance Act, in each case with respect to said person's relevant illness or injury. The same shall apply when such person is eligible for any medical compensation pursuant to the provisions of the Labor Standards Act (Act No. 49 of 1947), any medical compensation benefits, medical treatment benefits for multiple-job workers or medical treatment benefits under the provisions of the Industrial Accident Compensation Insurance Act (Act No. 50 of 1947), any medical compensation under the provisions of the National Public Officers' Accident Compensation Act (Act No. 191 of 1951; including cases where applied mutatis mutandis pursuant to any other Act), any medical compensation under the provisions of the Local Public Officers Accident Compensation Act (Act No. 121 of 1967) or a Prefectural or Municipal Ordinance under the same Act or any other benefit relating to medical services under any law or regulation as prescribed by Cabinet Order, or when any benefit relating to medical care is provided at the expense of the national government or a local government pursuant to any law or regulation other than these laws and regulations.
療養の給付又は入院時食事療養費、入院時生活療養費、保険外併用療養費、訪問看護療養費、特別療養費若しくは移送費の支給は、被保険者の当該疾病又は負傷につき、健康保険法、船員保険法、国家公務員共済組合法(他の法律において準用し、又は例による場合を含む。)、地方公務員等共済組合法若しくは高齢者の医療の確保に関する法律の規定によつて、医療に関する給付を受けることができる場合又は介護保険法の規定によつて、それぞれの給付に相当する給付を受けることができる場合には、行わない。労働基準法(昭和二十二年法律第四十九号)の規定による療養補償、労働者災害補償保険法(昭和二十二年法律第五十号)の規定による療養補償給付、複数事業労働者療養給付若しくは療養給付、国家公務員災害補償法(昭和二十六年法律第百九十一号。他の法律において準用する場合を含む。)の規定による療養補償、地方公務員災害補償法(昭和四十二年法律第百二十一号)若しくは同法に基づく条例の規定による療養補償その他政令で定める法令による医療に関する給付を受けることができるとき、又はこれらの法令以外の法令により国若しくは地方公共団体の負担において医療に関する給付が行われたときも、同様とする。
In cases where benefits under any law or regulation set forth in the preceding paragraph are benefits in kind relating to medical services and when any co-payment is made or actual costs are collected in relation to such benefits and when the amount of such co-payment or actual costs collected exceeds the amount of co-payment which would have been required under this Act had such benefits been provided as benefits for medical treatment pursuant to this Act (or, when the ratio of co-payment set forth in Article 42, paragraph (1) has been reduced pursuant to the provisions of Article 43, paragraph (1), the amount of co-payment calculated in accordance with the ratio after such reduction), or in cases where benefits under any law or regulation set forth in the preceding paragraph (excluding the Long-Term Care Insurance Act) are payments of medical expenses and when the amount of such payment is less than the amount of expenses for Dietary Treatment for inpatients, expenses for Living Support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses or transportation expenses which would have been payable had expenses for Dietary Treatment for inpatients, expenses for Living Support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses or transportation expenses been required pursuant to this Act with respect to the relevant medical treatment, then Municipalities and Societies shall pay to the insured person the difference between the relevant amounts in each case.
市町村及び組合は、前項に規定する法令による給付が医療に関する現物給付である場合において、その給付に関し一部負担金の支払若しくは実費徴収が行われ、かつ、その一部負担金若しくは実費徴収の額が、その給付がこの法律による療養の給付として行われたものとした場合におけるこの法律による一部負担金の額(第四十三条第一項の規定により第四十二条第一項の一部負担金の割合が減ぜられているときは、その減ぜられた割合による一部負担金の額)を超えるとき、又は前項に規定する法令(介護保険法を除く。)による給付が医療費の支給である場合において、その支給額が、当該療養につきこの法律による入院時食事療養費、入院時生活療養費、保険外併用療養費、療養費、訪問看護療養費、特別療養費又は移送費の支給をすべきものとした場合における入院時食事療養費、入院時生活療養費、保険外併用療養費、療養費、訪問看護療養費、特別療養費又は移送費の額に満たないときは、それぞれその差額を当該被保険者に支給しなければならない。
In the case referred to in the preceding paragraph, when the insured person has received the relevant medical treatment at or from a health insurance-covered medical institution, etc., Municipalities and Societies may, on behalf of such insured person, pay to such health insurance-covered medical institution, etc. expenses incurred in such medical treatment payable by said insured person to said health insurance-covered medical institution, etc. within the limits of the amount payable to said insured person pursuant to the provisions of the same paragraph; provided, however, that when the Municipality or Society concerned has reduced the ratio of co-payment pursuant to the provisions of Article 43, paragraph (1), the foregoing shall apply only where such insured person has received such medical treatment at or from one of the health insurance-covered medical institutions, etc. set forth in paragraph (2) of the same Article.
When a payment of expenses is made to the relevant Health Insurance-Covered Medical Institution, etc. pursuant to the provisions of the preceding paragraph, the insured person shall, to the extent of such payment, be deemed to have received a payment pursuant to the provisions of paragraph (2).
Article 57Co-payment Relating to an Insured Person Who is Not the Householder or Society Member
第五十七条(世帯主又は組合員でない被保険者に係る一部負担金等)
In making any co-payment or in paying any difference or medical expenses pursuant to the provisions of paragraph (3) of Article 43 or paragraph (2) of the preceding Article, when the relevant illness or injury is of an insured person who is not the Householder or Society member, the Householder or Society member of the household to which such insured person belongs shall make, or be obligated to make, co-payment and shall receive payment of the difference or medical expenses pursuant to paragraph (3) of Article 43 or paragraph (2) of the preceding Article, notwithstanding the provisions of the respective Articles pertaining to these matters.
Article 57-2High-Cost Medical Expenses
第五十七条の二(高額療養費)
When the amount of co-payment paid for benefits for medical treatment, or the amount obtained by deducting, from the amount of expenses incurred in medical treatment (excluding Dietary Treatment and Living Support; hereinafter the same shall apply in the following paragraph), the amount paid as medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing or special medical expenses with respect to expenses incurred in the relevant medical treatment or the amount equivalent to the difference paid pursuant to the provisions of Article 56, paragraph (2) (in paragraph (1) of the following Article referred to as the "amount of co-payment, etc."), is extremely large, Municipalities and Societies shall pay high-cost medical expenses to the relevant Householder or Society member; provided, however, that this shall not apply if no benefit for medical treatment, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing or special medical expenses were paid and no difference was paid pursuant to the provisions of Article 56, paragraph (2) with respect to the relevant medical treatment.
市町村及び組合は、療養の給付について支払われた一部負担金の額又は療養(食事療養及び生活療養を除く。次項において同じ。)に要した費用の額からその療養に要した費用につき保険外併用療養費、療養費、訪問看護療養費若しくは特別療養費として支給される額若しくは第五十六条第二項の規定により支給される差額に相当する額を控除した額(次条第一項において「一部負担金等の額」という。)が著しく高額であるときは、世帯主又は組合員に対し、高額療養費を支給する。ただし、当該療養について療養の給付、保険外併用療養費の支給、療養費の支給、訪問看護療養費の支給若しくは特別療養費の支給又は第五十六条第二項の規定による差額の支給を受けなかつたときは、この限りでない。
The requirements for payment and the amount of high-cost medical expenses and other necessary matters concerning the payment of high-cost medical expenses shall be prescribed by Cabinet Order by taking into consideration the impact of the burden of the expenses incurred in the relevant medical treatment on household finances, in particular the household finances of persons who continuously receive medical treatment over a long period, and the amount of expenses incurred in the medical treatment.
高額療養費の支給要件、支給額その他高額療養費の支給に関して必要な事項は、療養に必要な費用の負担の家計、とりわけ長期にわたつて継続的に療養を受ける者の家計に与える影響及び療養に要した費用の額を考慮して、政令で定める。
When the total sum of the amount of co-payment, etc. (or, where high-cost medical expenses set forth in paragraph (1) of the preceding Article are paid, the amount obtained by deducting the amount equivalent to the amount so paid), the amount to be borne by a user of Long-Term Care Service pursuant to the provisions of Article 51, paragraph (1) of the Long-Term Care Insurance Act (or, where expenses for High-Cost Long-Term Care Service set forth in the same paragraph are paid, the amount obtained by deducting the amount so paid) and the amount to be borne by a user of Preventive Long-Term Care Service pursuant to the provisions of Article 61, paragraph (1) of the same Act (or, where expenses for High-Cost Preventive Long-Term Care Service set forth in the same paragraph are paid, the amount obtained by deducting the amount so paid) is extremely large, Municipalities and Societies shall pay expenses for high-cost medical treatment combined with long-term care to the relevant Householder or Society member; provided, however, that this shall not apply if no benefit for medical treatment, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing or special medical expenses were paid and no difference was paid pursuant to the provisions of Article 56, paragraph (2) with respect to the medical treatment relevant to such amount of co-payment, etc.
市町村及び組合は、一部負担金等の額(前条第一項の高額療養費が支給される場合にあつては、当該支給額に相当する額を控除して得た額)並びに介護保険法第五十一条第一項に規定する介護サービス利用者負担額(同項の高額介護サービス費が支給される場合にあつては、当該支給額を控除して得た額)及び同法第六十一条第一項に規定する介護予防サービス利用者負担額(同項の高額介護予防サービス費が支給される場合にあつては、当該支給額を控除して得た額)の合計額が著しく高額であるときは、世帯主又は組合員に対し、高額介護合算療養費を支給する。ただし、当該一部負担金等の額に係る療養の給付、保険外併用療養費の支給、療養費の支給、訪問看護療養費の支給若しくは特別療養費の支給又は第五十六条第二項の規定による差額の支給を受けなかつたときは、この限りでない。
The provisions of paragraph (2) of the preceding Article shall apply mutatis mutandis to the payment of medical expenses combined with high-cost long-term care.
前条第二項の規定は、高額介護合算療養費の支給について準用する。