When a dependent of an insured person receives medical treatment from a medical institution providing services covered by health insurance that is selected by the dependent, dependent's medical expenses are paid to the insured person for expenses required for the medical treatment.
The amount of dependent medical expenses is the amount specified in item (i) below (the aggregate of that amount and the amount specified in item (ii) or (iii) if the medical treatment includes dietary treatment or living support, respectively):
the amount obtained by multiplying the amount of expenses calculated for the medical treatment (excluding dietary treatment and living support) (if the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred) by the ratio prescribed in (a) through (d) listed below in accordance with the classifications in (a) through (d):
if the first March 31 after the dependent's 6th birthday has passed and the month which contains the dependent's 70th birthday has not yet began:0.70;
被扶養者が六歳に達する日以後の最初の三月三十一日の翌日以後であって七十歳に達する日の属する月以前である場合 百分の七十
if the first March 31 after the dependent's 6th birthday has not yet passed:0.80;
被扶養者が六歳に達する日以後の最初の三月三十一日以前である場合 百分の八十
if the month which contains the dependent's 70th birthday has elapsed (excluding dependents prescribed in (d)):0.80;
被扶養者(ニに規定する被扶養者を除く。)が七十歳に達する日の属する月の翌月以後である場合 百分の八十
if the month which contains the 70th birthday of the dependent of an insured person listed in Article 74, paragraph (1), item (iii) or another insured person specified by Cabinet Order has elapsed:0.70;
第七十四条第一項第三号に掲げる場合に該当する被保険者その他政令で定める被保険者の被扶養者が七十歳に達する日の属する月の翌月以後である場合 百分の七十
the amount calculated by deducting, from the amount calculated for the dietary treatment (when that amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of expenses actually incurred), the amount of standard co-payment for dietary treatment; or
the amount calculated by deducting, from the amount calculated for the living support (when the amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred), the amount of standard co-payment for living support.
The amount of expenses for medical treatment referred to in item (i) of the preceding paragraph is calculated pursuant to the provisions of Article 76, paragraph (2) when medical treatment (excluding evaluation treatment, patient-requested treatment, and selective treatment) is received from a medical institution providing services covered by health insurance, and the provisions of Article 86, paragraph (2), item (i) when evaluation treatment, patient-requested treatment or selective treatment is received from a medical institution providing services covered by health insurance, the amount of expenses for dietary treatment for inpatients referred to in item (ii) of the preceding paragraph is calculated pursuant to the provisions of Article 85, paragraph (2), and the amount of expenses for living support for inpatients referred to in item (iii) of the preceding paragraph is calculated pursuant to the provisions of Article 85-2, paragraph (2).
When a dependent receives medical treatment at or from a hospital, clinic or pharmacy listed in Article 63, paragraph (3), item (i) or (ii), the insurer may, on behalf of the relevant insured person, pay to the hospital, clinic or pharmacy expenses incurred for the medical treatment payable by the dependent to the hospital, clinic or pharmacy within the limit of the amount payable to the insured person as expenses for dependent's medical treatment.
被扶養者が第六十三条第三項第一号又は第二号に掲げる病院若しくは診療所又は薬局から療養を受けたときは、保険者は、その被扶養者が当該病院若しくは診療所又は薬局に支払うべき療養に要した費用について、家族療養費として被保険者に対し支給すべき額の限度において、被保険者に代わり、当該病院若しくは診療所又は薬局に支払うことができる。
When a payment pursuant to the provisions of the preceding paragraph is made, it is deemed that dependent's medical expenses are paid to the insured person.
When a dependent receives medical treatment from a hospital, clinic, or pharmacy listed in Article 63, paragraph (3), item (iii), and the insurer exempts the insured person from payment of an amount equivalent to the amount to be paid as dependent's medical expenses among the expenses required for medical treatment to be paid by the dependent, it is deemed that dependent's medical expenses are paid to the insured person.
被扶養者が第六十三条第三項第三号に掲げる病院若しくは診療所又は薬局から療養を受けた場合において、保険者がその被扶養者の支払うべき療養に要した費用のうち家族療養費として被保険者に支給すべき額に相当する額の支払を免除したときは、被保険者に対し家族療養費の支給があったものとみなす。
The provisions of Article 63, Article 64, Article 70, paragraph (1), Article 72, paragraph (1), Article 73, Article 76, paragraphs (3) through (6), Article 78, Article 84, paragraph (1), Article 85, paragraph (8), Article 87, and Article 98 apply mutatis mutandis to the payment of dependent's medical expenses and to dependent's medical treatment.
The provisions of Article 75 apply mutatis mutandis to payment of the amount calculated by deducting, from the amount of expenses calculated for the relevant medical treatment pursuant to the provisions of paragraph (3) in the case referred to in paragraph (4) (when the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred), the amount payable as dependent's medical expenses with respect to expenses incurred in the medical treatment.
Read this with the articles around it
(Dependent's Medical Expenses)
the amount obtained by multiplying the amount of expenses calculated for the medical treatment (excluding dietary treatment and living support)…
当該療養(食事療養及び生活療養を除く。)につき算定した費用の額(その額が現に当該療養に要した費用の額を超えるときは、当該現に療養に要した費用の額)に次のイからニまでに掲げる場合の区分に応じ、当該イからニまでに定める割合を乗じて得た額
Open this provision(Dependent's Medical Expenses)
the amount calculated by deducting, from the amount calculated for the dietary treatment (when that amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of…
当該食事療養につき算定した費用の額(その額が現に当該食事療養に要した費用の額を超えるときは、当該現に食事療養に要した費用の額)から食事療養標準負担額を控除した額
Open this provision(Dependent's Medical Expenses)
the amount calculated by deducting, from the amount calculated for the living support (when the amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses…
当該生活療養につき算定した費用の額(その額が現に当該生活療養に要した費用の額を超えるときは、当該現に生活療養に要した費用の額)から生活療養標準負担額を控除した額
Open this provision(Dependent's Medical Expenses)
The amount of expenses for medical treatment referred to in item (i) of the preceding paragraph is calculated pursuant to the provisions of Article 76…
前項第一号の療養についての費用の額の算定に関しては、保険医療機関等から療養(評価療養、患者申出療養及び選定療養を除く。)を受ける場合にあっては第七十六条第二項の費用の額の算定、保険医療機関等から評価療養、患者申出療養又は選定療養を受ける場合にあっては第八十六条第二項第一号の費用の額の算定…
Open this provision(Dependent's Medical Expenses)
When a dependent receives medical treatment at or from a hospital, clinic or pharmacy listed in Article 63, paragraph (3), item (i) or (ii), the insurer may, on behalf of the relevant insured person…
被扶養者が第六十三条第三項第一号又は第二号に掲げる病院若しくは診療所又は薬局から療養を受けたときは、保険者は、その被扶養者が当該病院若しくは診療所又は薬局に支払うべき療養に要した費用について、家族療養費として被保険者に対し支給すべき額の限度において、被保険者に代わり、当該病院若しくは診療所又は薬局に支払うことができる。
Open this provision(Benefits for Medical Treatment)
With regard to sickness and injury of insured persons, benefits for medical treatment are paid as listed below:
被保険者の疾病又は負傷に関しては、次に掲げる療養の給付を行う。
Open this provision(Benefits for Medical Treatment)
a hospital or clinic designated by the Minister of Health, Labour and Welfare (if the hospital or clinic has received a designation excluding all or some of its beds pursuant to the provisions of…
厚生労働大臣の指定を受けた病院若しくは診療所(第六十五条の規定により病床の全部又は一部を除いて指定を受けたときは、その除外された病床を除く。以下「保険医療機関」という。)又は薬局(以下「保険薬局」という。)
Open this provision(Benefits for Medical Treatment)
a hospital, clinic, or pharmacy which provides medical care or prescriptions to an insured person administered by a specific insurer and which is specified by the insurer; and
特定の保険者が管掌する被保険者に対して診療又は調剤を行う病院若しくは診療所又は薬局であって、当該保険者が指定したもの
Open this provision(Benefits for Medical Treatment)
a hospital, clinic, or pharmacy established by an insurer which is a health insurance society.
健康保険組合である保険者が開設する病院若しくは診療所又は薬局
Open this provision(Physicians Providing Health Insurance Treatment or Pharmacists Filling Health Insurance Prescriptions)
A physician or dentist engaged in medical treatment covered by health insurance at a medical institution providing services covered by health insurance or a pharmacist engaged in prescription covered…
保険医療機関において健康保険の診療に従事する医師若しくは歯科医師又は保険薬局において健康保険の調剤に従事する薬剤師は、厚生労働大臣の登録を受けた医師若しくは歯科医師(以下「保険医」と総称する。)又は薬剤師(以下「保険薬剤師」という。)でなければならない。
Open this provision(Responsibilities of Medical Institutions Providing Services Covered by Health Insurance or Pharmacies Providing Services Covered by Health Insurance)
A medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance must put physicians providing health insurance treatment who are…
保険医療機関又は保険薬局は、当該保険医療機関において診療に従事する保険医又は当該保険薬局において調剤に従事する保険薬剤師に、第七十二条第一項の厚生労働省令で定めるところにより、診療又は調剤に当たらせるほか、厚生労働省令で定めるところにより、療養の給付を担当しなければならない。
Open this provision(Responsibilities of Physicians Providing Health Insurance Treatment or Pharmacists Filling Health Insurance Prescriptions)
A physician providing health insurance treatment at a medical institution providing services covered by health insurance or a pharmacist filling health insurance prescriptions at a pharmacy providing…
保険医療機関において診療に従事する保険医又は保険薬局において調剤に従事する保険薬剤師は、厚生労働省令で定めるところにより、健康保険の診療又は調剤に当たらなければならない。
Open this provision(Guidance by the Minister of Health, Labour and Welfare)
A medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance, and the physician providing health insurance treatment or the…
保険医療機関及び保険薬局は療養の給付に関し、保険医及び保険薬剤師は健康保険の診療又は調剤に関し、厚生労働大臣の指導を受けなければならない。
Open this provision(Amount of Co-Payment)
if the month in which the person's 70th birthday falls has elapsed and the amount of remuneration calculated as specified by Cabinet Order is not less than the amount specified by Cabinet Order:0.30.
七十歳に達する日の属する月の翌月以後である場合であって、政令で定めるところにより算定した報酬の額が政令で定める額以上であるとき 百分の三十
Open this provisionWhen co-payment is made pursuant to the provisions of paragraph (1) of the preceding Article, if the amount of co-payment referred to in the same paragraph is a figure with less than five…
前条第一項の規定により一部負担金を支払う場合においては、同項の一部負担金の額に五円未満の端数があるときは、これを切り捨て、五円以上十円未満の端数があるときは、これを十円に切り上げるものとする。
Open this provision(Expenses for Benefits for Medical Treatment)
The amount of expenses for benefits for medical treatment referred to in the preceding paragraph is to be calculated as specified by the Minister of Health, Labour and Welfare.
前項の療養の給付に要する費用の額は、厚生労働大臣が定めるところにより、算定するものとする。
Open this provision(Expenses for Benefits for Medical Treatment)
An insurer may, with the authorization of the Minister of Health, Labour and Welfare, specify otherwise in a contract with a medical institution providing services covered by health insurance or…
保険者は、厚生労働大臣の認可を受けて、保険医療機関又は保険薬局との契約により、当該保険医療機関又は保険薬局において行われる療養の給付に関する第一項の療養の給付に要する費用の額につき、前項の規定により算定される額の範囲内において、別段の定めをすることができる。
Open this provision(Expenses for Benefits for Medical Treatment)
When receiving a claim for expenses incurred in providing medical services from a medical institution providing services covered by health insurance or pharmacy providing services covered by health…
保険者は、保険医療機関又は保険薬局から療養の給付に関する費用の請求があったときは、第七十条第一項及び第七十二条第一項の厚生労働省令並びに前二項の定めに照らして審査の上、支払うものとする。
Open this provision(Expenses for Benefits for Medical Treatment)
An insurer may delegate affairs concerning the examination and payment pursuant to the provisions of the preceding paragraph to the Medical Information Infrastructure and Medical Fee Examination and…
保険者は、前項の規定による審査及び支払に関する事務を医療情報基盤・診療報酬審査支払機構法(昭和二十三年法律第百二十九号)による医療情報基盤・診療報酬審査支払機構(以下「基盤機構」という。)又は国民健康保険法第四十五条第五項に規定する国民健康保険団体連合会(以下「国保連合会」という。)に委託することができる。
Open this provision(Expenses for Benefits for Medical Treatment)
Beyond what is provided for in the preceding paragraphs, necessary matters concerning claims for expenses incurred in providing medical services at a medical institution providing services covered by…
前各項に定めるもののほか、保険医療機関又は保険薬局の療養の給付に関する費用の請求に関して必要な事項は、厚生労働省令で定める。
Open this provision(Reports by Medical Institutions Providing Services Covered by Health Insurance or Pharmacies Providing Services Covered by Health Insurance)
When the Minister of Health, Labour and Welfare finds it necessary in relation to benefits for medical treatment, the minister or governor may order a medical institution providing services covered…
厚生労働大臣は、療養の給付に関して必要があると認めるときは、保険医療機関若しくは保険薬局若しくは保険医療機関若しくは保険薬局の開設者若しくは管理者、保険医、保険薬剤師その他の従業者であった者(以下この項において「開設者であった者等」という。)に対し報告若しくは診療録その他の帳簿書類の提出若しくは提示を命じ…
Open this provision(Benefits for Medical Treatment at Hospitals Designated by Insurers)
Rules on benefits for medical treatment, and on medical care and prescription services covered by health insurance and provided by hospitals, clinics, and pharmacies listed in Article 63…
第六十三条第三項第二号及び第三号に掲げる病院若しくは診療所又は薬局において行われる療養の給付及び健康保険の診療又は調剤に関する準則については、第七十条第一項及び第七十二条第一項の厚生労働省令の例による。
Open this provision(Living Support Expenses for Inpatients)
The amount of living support expenses for inpatients is the amount obtained by deducting the amount specified by the Minister of Health, Labor and Welfare taking into consideration an amount…
入院時生活療養費の額は、当該生活療養につき生活療養に要する平均的な費用の額を勘案して厚生労働大臣が定める基準により算定した費用の額(その額が現に当該生活療養に要した費用の額を超えるときは、当該現に生活療養に要した費用の額)から…
Open this provision(Dietary Treatment Expenses for Inpatients)
The amount of dietary treatment expenses for inpatients is the amount obtained by deducting the amount specified by the Minister of Health, Labor and Welfare taking into consideration the status of…
入院時食事療養費の額は、当該食事療養につき食事療養に要する平均的な費用の額を勘案して厚生労働大臣が定める基準により算定した費用の額(その額が現に当該食事療養に要した費用の額を超えるときは、当該現に食事療養に要した費用の額)から…
Open this provision(Dietary Treatment Expenses for Inpatients)
Upon acceptance of a payment of expenses incurred for dietary treatment, the hospital or clinic listed in the items of Article 63, paragraph (3) must issue a receipt therefor to the relevant insured…
第六十三条第三項各号に掲げる病院又は診療所は、食事療養に要した費用につき、その支払を受ける際、当該支払をした被保険者に対し、厚生労働省令で定めるところにより、領収証を交付しなければならない。
Open this provision(Medical Expenses Combined with Treatment Outside Insurance Coverage)
the amount calculated by deducting, from the amount of expenses calculated for the medical treatment (excluding dietary treatment and living support) pursuant to the rules prescribed by the Minister…
当該療養(食事療養及び生活療養を除く。)につき第七十六条第二項の定めを勘案して厚生労働大臣が定めるところにより算定した費用の額(その額が現に当該療養に要した費用の額を超えるときは、当該現に療養に要した費用の額)から、その額に第七十四条第一項各号に掲げる場合の区分に応じ…
Open this provision(Medical Expenses)
When an insurer finds it difficult to pay benefits for medical treatment, expenses for dietary treatment for inpatients, living support expenses for inpatients…
保険者は、療養の給付若しくは入院時食事療養費、入院時生活療養費若しくは保険外併用療養費の支給(以下この項において「療養の給付等」という。)を行うことが困難であると認めるとき、又は被保険者が保険医療機関等以外の病院、診療所、薬局その他の者から診療、薬剤の支給若しくは手当を受けた場合において…
Open this provision(Insured Persons Who Have Become a Day Worker and Their Dependents)
If an insured person has lost eligibility and become a specially-insured day laborer or a dependent thereof, and, at the time of loss of the eligibility…
被保険者が資格を喪失し、かつ、日雇特例被保険者又はその被扶養者となった場合において、その資格を喪失した際に療養の給付、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…
Open this provisioninsured person
「被保険者」
A person employed at an applicable place of business (適用事業所), or an insured person with optional and continued coverage (任意継続被保険者); the persons listed in the items of Article 3, paragraph (1) — among them some temporary, seasonal and short-time workers and persons insured under late-stage elderly medical care (後期高齢者医療) — cannot be insured persons, except as specially-insured day laborers (日雇特例被保険者).
Defined inArticle 3, paragraph (1)· applies throughout the law
dependentmachine translation
「被扶養者」
A person who lives in Japan — or who lives abroad but whom a Ministry of Health, Labour and Welfare Order (厚生労働省令) treats as based in Japan, such as a student studying abroad — and who is mainly supported by an insured person (including a former specially-insured day laborer, 日雇特例被保険者): the insured person's lineal ascendants, spouse (including a de facto spouse), children, grandchildren and siblings, and, if they belong to the insured person's household, other relatives within the third degree of kinship and a de facto spouse's parents and children, also after that spouse's death; persons with late-stage elderly medical care insurance (後期高齢者医療の被保険者等) and others the Order excludes are not dependents.
Defined inArticle 3, paragraph (7)· applies throughout the law
medical institution providing services covered by health insurance, etc.machine translation
「保険医療機関等」
The hospitals, clinics and pharmacies listed in Article 63, paragraph (3) from which insured persons receive benefits for medical treatment (療養の給付): those designated by the Minister of Health, Labour and Welfare, those an insurer designates for the persons it insures, and those a health insurance society (健康保険組合) runs as insurer.
Defined inArticle 3, paragraph (13)
dietary treatment
「食事療養」
Meals provided as treatment together with inpatient care in a hospital or clinic (the treatment in Article 63, paragraph (1), item (v)), other than those given with a stay in a sanatorium ward (療養病床) to an insured person who is, at the time, past the month in which they reach the age of 65 (an insured person undergoing special long-term hospitalization, 特定長期入院被保険者).
Short name set inArticle 63, paragraph (2), item (i)
living support
「生活療養」
Meals, and a suitable care environment as to temperature, lighting and water supply, provided together with inpatient care (Article 63, paragraph (1), item (v)) to an insured person undergoing special long-term hospitalization (特定長期入院被保険者).
Short name set inArticle 63, paragraph (2), item (ii)
evaluation treatment
「評価療養」
Treatment using advanced medical technology that the Minister of Health, Labour and Welfare specifies, and other treatment the Minister specifies as needing to be evaluated, with a view to providing appropriate medical care efficiently, for whether it should be covered by medical treatment benefits (療養の給付) — other than patient-requested treatment (患者申出療養).
Short name set inArticle 63, paragraph (2), item (iii)
patient-requested treatment
「患者申出療養」
Medical treatment using advanced medical technology that the Minister of Health, Labour and Welfare designates as needing evaluation, at the request of the person who wishes to receive it, of whether it should be covered by the benefits for medical treatment (療養の給付), with a view to providing appropriate medical care efficiently.
Short name set inArticle 63, paragraph (2), item (iv)
selective treatment
「選定療養」
A special hospital room the insured person chooses, and other treatment of kinds the Minister of Health, Labour and Welfare specifies — one of the kinds of treatment Article 63, paragraph (2) leaves out of medical treatment benefits (療養の給付).
Short name set inArticle 63, paragraph (2), item (v)
standard co-payment for dietary treatment
「食事療養標準負担額」
The amount the Minister of Health, Labour and Welfare sets, in view of average household spending on food and the average cost of meals at specified long-term care insurance facilities (特定介護保険施設等), that is deducted from the cost of dietary treatment (食事療養) in working out inpatient dietary treatment expenses (入院時食事療養費); a separate amount applies to persons a Ministry of Health, Labour and Welfare Order (厚生労働省令) specifies in view of their income and other circumstances.
Short name set inArticle 85, paragraph (2)
standard co-payment for living support
「生活療養標準負担額」
The amount the Minister of Health, Labour and Welfare sets, taking account of average household spending on food, heating, lighting and water and of the base costs of meals and accommodation under Article 51-3, paragraph (2) of the Long-Term Care Insurance Act, which is deducted from the cost of living support (生活療養) to give the living support expenses for inpatients (入院時生活療養費); a different amount applies to people a Ministry of Health, Labour and Welfare Order (厚生労働省令) specifies in view of their income, condition, treatment and other circumstances.
Short name set inArticle 85-2, paragraph (2)