When an insured person, pursuant to Order of the Ministry of Health, Labour and Welfare, receives confirmation of being an insured person by electronic eligibility confirmation, etc. from a medical institution providing services covered by health insurance, etc. that the person selected, and receives evaluation treatment, patient-requested treatment or selective treatment, medical expenses combined with treatment outside insurance coverage are paid for expenses required for that treatment.
The amount of medical expenses combined with treatment outside insurance coverage is the amount listed in item (i) below (the aggregate of that amount and the amount listed in item (ii) if the medical treatment includes dietary treatment, or the aggregate of that amount and the amount listed in item (iii) if the medical treatment includes living support):
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 of Health, Labour and Welfare taking into account the provisions of Article 76, paragraph (2) (when the calculated amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred in the medical treatment), the amount obtained by multiplying that amount by the applicable ratio specified in the items of Article 74, paragraph (1) (if any of the measures listed in the items of Article 75-2, paragraph (1) need to be taken with respect to the co-payment referred to in the same paragraph for benefits for medical treatment, the amount calculated as if the relevant measures were taken), in accordance with the classifications listed in the in the same items;
the amount calculated by deducting the amount of standard co-payment for dietary treatment from the amount calculated for the dietary treatment pursuant to the standards set by the Minister of Health, Labour and Welfare prescribed in the provisions of Article 85, paragraph (2) (when the calculated amount exceeds the amount of expenses actually incurred for the dietary treatment, the amount of expenses actually incurred for the dietary treatment); and
the amount calculated by deducting the amount of standard co-payment for living support from the amount calculated for the living support pursuant to the standards set by the Minister of Health, Labour and Welfare prescribed in the provisions of paragraph (2) of the preceding Article (when the amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred in the living support).
When intending to specify the matters as prescribed in item (i), the Minister of Health, Labour, and Welfare is to consult with the Central Social Insurance Medical Council.
厚生労働大臣は、前項第一号の定めをしようとするときは、中央社会保険医療協議会に諮問するものとする。
The provisions of Article 64, Article 70, paragraph (1), Article 72, paragraph (1), Article 73, Article 76, paragraphs (3) through (6), Article 77, Article 78, Article 84, paragraph (1), Article 85, paragraphs (5) through (8) apply mutatis mutandis to the payment of evaluation treatment, patient-requested treatment, and selective treatment received at or from a medical institution providing services covered by health insurance, as well as medical expenses combined with treatment outside insurance coverage associated with the received treatment.
The provisions of Article 75 apply mutatis mutandis to 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 pursuant to the provisions of paragraph (2) in the case referred to in Article 85, paragraph (5) as applied mutatis mutandis pursuant to the preceding paragraph (when the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred in the medical treatment).
Read this with the articles around it
(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)
A person who receives benefits for medical treatment from a medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance pursuant to…
第六十三条第三項の規定により保険医療機関又は保険薬局から療養の給付を受ける者は、その給付を受ける際、次の各号に掲げる場合の区分に応じ、当該給付につき第七十六条第二項又は第三項の規定により算定した額に当該各号に定める割合を乗じて得た額を、一部負担金として、当該保険医療機関又は保険薬局に支払わなければならない。
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(Special Provisions for the Amount of Co-payment)
An insurer may take any of the following measures with respect to an insured person who is in a disaster or other special circumstances specified by Order of the Ministry of Health…
保険者は、災害その他の厚生労働省令で定める特別の事情がある被保険者であって、保険医療機関又は保険薬局に第七十四条第一項の規定による一部負担金を支払うことが困難であると認められるものに対し、次の措置を採ることができる。
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 provisionSurvey by the Minister of Health, Labour and Welfare Concerning the Determination of the Amount of Expenses Required for Benefits for Medical Treatment
The Minister of Health, Labour and Welfare may conduct a necessary survey to ensure the appropriateness of the provisions for chemicals among the provisions of paragraph (2) of the preceding Article…
厚生労働大臣は、前条第二項の定めのうち薬剤に関する定めその他厚生労働大臣の定めを適正なものとするため、必要な調査を行うことができる。
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)
When an insured person (excluding insured persons undergoing special long-term hospitalization; the same applies hereinafter in this Article) has received dietary treatment at or from a hospital or…
被保険者（特定長期入院被保険者を除く。以下この条において同じ。）が第六十三条第三項第一号又は第二号に掲げる病院又は診療所から食事療養を受けたときは、保険者は、その被保険者が当該病院又は診療所に支払うべき食事療養に要した費用について、入院時食事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…
Open this provision(Dietary Treatment Expenses for Inpatients)
When a payment pursuant to the provisions of the preceding paragraph is paid, it is deemed that the relevant dietary treatment expenses for inpatients are paid to the insured person.
前項の規定による支払があったときは、被保険者に対し入院時食事療養費の支給があったものとみなす。
Open this provision(Dietary Treatment Expenses for Inpatients)
When an insured person receives dietary treatment from a hospital or clinic listed in Article 63, paragraph (3), item (iii), if the insurer exempts the insured person from payment of an amount…
被保険者が第六十三条第三項第三号に掲げる病院又は診療所から食事療養を受けた場合において、保険者がその被保険者の支払うべき食事療養に要した費用のうち入院時食事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、入院時食事療養費の支給があったものとみなす。
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 of medical expenses combined with treatment outside insurance coverage is the amount listed in item (i) below…
保険外併用療養費の額は、第一号に掲げる額（当該療養に食事療養が含まれるときは当該額及び第二号に掲げる額の合算額、当該療養に生活療養が含まれるときは当該額及び第三号に掲げる額の合算額）とする。
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 Combined with Treatment Outside Insurance Coverage)
the amount calculated by deducting the amount of standard co-payment for dietary treatment from the amount calculated for the dietary treatment pursuant to the standards set by the Minister of Health…
当該食事療養につき第八十五条第二項に規定する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）から食事療養標準負担額を控除した額
Open this provision(Medical Expenses Combined with Treatment Outside Insurance Coverage)
the amount calculated by deducting the amount of standard co-payment for living support from the amount calculated for the living support pursuant to the standards set by the Minister of Health…
当該生活療養につき前条第二項に規定する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）から生活療養標準負担額を控除した額
Open this provision(Medical Expenses Combined with Treatment Outside Insurance Coverage)
The provisions of Article 64, Article 70, paragraph (1), Article 72, paragraph (1), Article 73, Article 76, paragraphs (3) through (6), Article 77, Article 78, Article 84, paragraph (1), Article 85…
第六十四条、第七十条第一項、第七十二条第一項、第七十三条、第七十六条第三項から第六項まで、第七十七条、第七十八条、第八十四条第一項及び第八十五条第五項から第八項までの規定は、保険医療機関等から受けた評価療養、患者申出療養及び選定療養並びにこれらに伴う保険外併用療養費の支給について準用する。
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
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)
electronic eligibility confirmation, etc.machine translation
「電子資格確認等」
Electronic eligibility confirmation (電子資格確認) or another method a Ministry of Health, Labour and Welfare Order (厚生労働省令) sets, by which a person seeking medical treatment benefits (療養の給付) is confirmed as an insured person by the hospital, clinic or pharmacy of their choice among those listed in Article 63, paragraph (3).
Short name set inArticle 63, paragraph (3)
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)