Article 43-2Requirements for Payment and Amount of Expenses for High-cost Medical Treatment Combined with Long-term Care
第四十三条の二（高額介護合算療養費の支給要件及び支給額）
Expenses for high-cost medical treatment combined with long-term care are to be paid to the insured person on the reference date where the amount (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care" in this paragraph) obtained by deducting the total payment for combined long-term care for persons aged 70 or over (meaning the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over under the following paragraph from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over prescribed in that paragraph (or zero, where that amount is equal to or less than the payment threshold specified by the Minister of Health, Labour and Welfare in consideration of the costs required for administering the payment of expenses for high-cost medical treatment combined with long-term care (hereinafter referred to as the "payment threshold" in this Article) or where the proviso to that paragraph applies to the calculation of that household total of co-payments, etc. combined with long-term care for persons aged 70 or over)) from the total sum of the following amounts exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation, and the amount of those expenses is to be the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation from the household total of co-payments, etc. combined with long-term care by the apportionment rate for the combined long-term care calculation (meaning the rate obtained by dividing the amount obtained by deducting the amount of expenses for high-cost medical treatment combined with long-term care to be paid under the provisions of the following paragraph from the amount listed in item (i), by the household total of co-payments, etc. combined with long-term care); provided, however, that this does not apply where the total sum of the amounts listed in that item through item (v) or the total sum of the amounts listed in items (vi) and (vii) is zero.
高額介護合算療養費は、次に掲げる額を合算した額から七十歳以上介護合算支給総額（次項に規定する七十歳以上介護合算一部負担金等世帯合算額から同項の七十歳以上介護合算算定基準額を控除した額（当該額が高額介護合算療養費の支給の事務の執行に要する費用を勘案して厚生労働大臣が定める支給基準額（以下この条において「支給基準額」という。）以下である場合又は当該七十歳以上介護合算一部負担金等世帯合算額の算定につき同項ただし書に該当する場合には、零とする。）をいう。）を控除した額（以下この項において「介護合算一部負担金等世帯合算額」という。）が介護合算算定基準額に支給基準額を加えた額を超える場合に基準日被保険者に支給するものとし、その額は、介護合算一部負担金等世帯合算額から介護合算算定基準額を控除した額に介護合算按分率（第一号に掲げる額から次項の規定により支給される高額介護合算療養費の額を控除した額を、介護合算一部負担金等世帯合算額で除して得た率をいう。）を乗じて得た額とする。ただし、同号から第五号までに掲げる額を合算した額又は第六号及び第七号に掲げる額を合算した額が零であるときは、この限りでない。
the total sum of the following amounts relating to medical treatment (including medical treatment under continued benefits) that the insured person on the reference date or a dependent thereof respectively received during the calculation period as an insured person of the relevant insurer or a dependent thereof (where high-cost medical expenses are paid pursuant to Article 41, paragraphs (1) through (5), Article 41-2 or Article 41-3, the amount after deducting the amount paid, and where money or goods to reduce the burden relating to the following amounts are provided as other benefits prescribed in Article 53 of the Act, the amount after deducting the amount equivalent to that money or those goods):
the total sum of the amounts listed in Article 41, paragraph (1), item (i), (a) through (f) relating to that medical treatment (excluding treatment subject to specified benefits) (for those relating to that medical treatment on or before the month that includes the day on which the person reaches the age of 70, limited to those of 21,000 yen or more for that medical treatment received from each single hospital, etc. in the same month (10,500 yen or more for those relating to medical treatment under the special rule on reaching age 75));
当該療養（特定給付対象療養を除く。）に係る第四十一条第一項第一号イからヘまでに掲げる額（七十歳に達する日の属する月以前の当該療養に係るものにあっては、同一の月にそれぞれ一の病院等から受けた当該療養について二万千円（七十五歳到達時特例対象療養に係るものにあっては、一万五百円）以上のものに限る。）を合算した額
the total sum of the amounts that the person who received that medical treatment (limited to treatment subject to specified benefits) still has to bear for that treatment (for those relating to treatment subject to specified benefits on or before the month that includes the day on which the person reaches the age of 70, limited to those for which the amounts listed in Article 41, paragraph (1), item (i), (a) through (f) relating to that treatment subject to specified benefits are 21,000 yen or more for that treatment subject to specified benefits received from each single hospital, etc. in the same month (10,500 yen or more for those relating to medical treatment under the special rule on reaching age 75));
当該療養（特定給付対象療養に限る。）について、当該療養を受けた者がなお負担すべき額（七十歳に達する日の属する月以前の特定給付対象療養に係るものにあっては、当該特定給付対象療養に係る第四十一条第一項第一号イからヘまでに掲げる額が同一の月にそれぞれ一の病院等から受けた当該特定給付対象療養について二万千円（七十五歳到達時特例対象療養に係るものにあっては、一万五百円）以上のものに限る。）を合算した額
the total sum prescribed in item (i) for medical treatment that the insured person on the reference date received while that person was an insured person of the insurer of another health insurance in the calculation period, or medical treatment that a person who was a dependent of that person received while being a dependent of that person;
the total sum prescribed in item (i) for medical treatment (including medical treatment under continued benefits) that the dependent on the reference date received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person;
the total sum prescribed in item (i) for medical treatment that the dependent on the reference date received while that person was an insured person of the insurer of another health insurance in the calculation period, or medical treatment that a person who was a dependent of that person received while being a dependent of that person;
the amount calculated, as provided by Order of the Ministry of Health, Labour and Welfare, as an amount equivalent to the total sum prescribed in item (i) for medical treatment (excluding the medical treatment prescribed in the preceding items) that the member, etc. received while the insured person on the reference date or the dependent on the reference date was a member, etc. (meaning a member, etc. prescribed in Article 41-2, paragraph (9); the same applies hereinafter in this item and paragraph (5)) in the calculation period, or medical treatment that a person who was a dependent, etc. (meaning a dependent, etc. prescribed in paragraph (10) of that Article; the same applies hereinafter in this item and paragraph (5)) of that member, etc. received while being a dependent, etc. thereof;
the total sum of the amounts listed in Article 22-2-2, paragraph (2), items (i) and (ii) of the Order for Enforcement of the Long-Term Care Insurance Act (Cabinet Order No. 412 of 1998) relating to in-home services, etc. (meaning in-home services, etc. prescribed in paragraph (1) of that Article; the same applies in the following paragraph) that the insured person on the reference date or the dependent on the reference date received during the calculation period (where expenses for high-cost long-term care service are paid pursuant to the provisions of paragraph (2) of that Article, the amount after deducting the amount paid);
the total sum of the amounts listed in Article 22-2-2, paragraph (2), items (iii) and (iv) of the Order for Enforcement of the Long-Term Care Insurance Act relating to preventive long-term care services, etc. (meaning preventive long-term care services, etc. prescribed in paragraph (2) of that Article; the same applies in the following paragraph) that the insured person on the reference date or the dependent on the reference date received during the calculation period (where expenses for high-cost preventive long-term care service are paid pursuant to the provisions of Article 29-2-2, paragraph (2) of that Order, the amount after deducting the amount paid).
Where the total sum (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care for persons aged 70 or over" in this paragraph) of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare as amounts equivalent to those relating to medical treatment received on or after the month following the month that includes the day on which the person reaches the age of 70, or in-home services, etc. or preventive long-term care services, etc. (hereinafter referred to as "services subject to combination for persons aged 70 or over" in this paragraph and paragraph (6)), among the amounts listed in the items of the preceding paragraph, exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation for persons aged 70 or over, the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over by the apportionment rate for the combined long-term care calculation for persons aged 70 or over (meaning the rate obtained by dividing the amount calculated as provided by Order of the Ministry of Health, Labour and Welfare as an amount equivalent to the amount listed in item (i) of the preceding paragraph relating to services subject to combination for persons aged 70 or over, by the household total of co-payments, etc. combined with long-term care for persons aged 70 or over) is paid to the insured person on the reference date as expenses for high-cost medical treatment combined with long-term care; provided, however, that this does not apply where the total sum of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare as amounts equivalent to the amounts listed in items (i) through (v) of the preceding paragraph relating to services subject to combination for persons aged 70 or over, or the total sum of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare as amounts equivalent to the amounts listed in items (vi) and (vii) of that paragraph relating to services subject to combination for persons aged 70 or over, is zero.
前項各号に掲げる額のうち、七十歳に達する日の属する月の翌月以後に受けた療養又は居宅サービス等若しくは介護予防サービス等（以下この項及び第六項において「七十歳以上合算対象サービス」という。）に係る額に相当する額として厚生労働省令で定めるところにより算定した額を合算した額（以下この項において「七十歳以上介護合算一部負担金等世帯合算額」という。）が七十歳以上介護合算算定基準額に支給基準額を加えた額を超える場合は、七十歳以上介護合算一部負担金等世帯合算額から七十歳以上介護合算算定基準額を控除した額に七十歳以上介護合算按分率（七十歳以上合算対象サービスに係る前項第一号に掲げる額に相当する額として厚生労働省令で定めるところにより算定した額を、七十歳以上介護合算一部負担金等世帯合算額で除して得た率をいう。）を乗じて得た額を高額介護合算療養費として基準日被保険者に支給する。ただし、七十歳以上合算対象サービスに係る前項第一号から第五号までに掲げる額に相当する額として厚生労働省令で定めるところにより算定した額を合算した額又は七十歳以上合算対象サービスに係る同項第六号及び第七号に掲げる額に相当する額として厚生労働省令で定めるところにより算定した額を合算した額が零であるときは、この限りでない。
The provisions of the preceding two paragraphs apply mutatis mutandis to the payment of expenses for high-cost medical treatment combined with long-term care to a person who was an insured person of the relevant insurer during the calculation period (limited to a dependent on the reference date). In this case, the phrase "listed in item (i)" in paragraph (1) is deemed to be replaced with "listed in item (iii)", the phrase "that item" in the proviso to that paragraph with "item (i)", and the phrase "item (i) of the preceding paragraph" in the preceding paragraph with "item (iii) of the preceding paragraph".
The provisions of paragraphs (1) and (2) apply mutatis mutandis to the payment of expenses for high-cost medical treatment combined with long-term care to a person who was an insured person of the relevant insurer during the calculation period (limited to a person who, on the reference date, is an insured person of the insurer of another health insurance or a dependent thereof). In this case, the phrase "the amount listed in item (i)" in paragraph (1) is deemed to be replaced with "the total sum prescribed in item (i) for medical treatment (including medical treatment under continued benefits) that the person prescribed in paragraph (4) received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person", the phrase "the insured person on the reference date" in item (i) of that paragraph with "an insured person of the insurer of another health insurance (limited to a person who, on the reference date, is an insured person of the insurer of that other health insurance; hereinafter referred to as the "insured person on the reference date" in this paragraph and the following paragraph)", "of the relevant insurer" with "of the insurer of that other health insurance (hereinafter referred to as the "insurer on the reference date" in this paragraph)", the phrase "another health insurance" in item (ii) of that paragraph with "a health insurance other than that of the insurer on the reference date", the phrase "the dependent on the reference date" in item (iii) of that paragraph with "a dependent of the insured person on the reference date (limited to a person who, on the reference date, is a dependent of an insured person of the insurer on the reference date; hereinafter referred to as the "dependent on the reference date" in this paragraph)", "of the relevant insurer" with "of the insurer on the reference date", the phrase "another health insurance" in item (iv) of that paragraph with "a health insurance other than that of the insurer on the reference date", and the phrase "the amount listed in item (i) of the preceding paragraph relating to services subject to combination for persons aged 70 or over" in paragraph (2) with "the total sum prescribed in item (i) of the preceding paragraph for medical treatment (limited to medical treatment received on or after the month following the month that includes the day on which the person reaches the age of 70, and including medical treatment under continued benefits) that the person prescribed in paragraph (4) received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (limited to medical treatment received on or after the month following the month that includes the day on which the person reaches the age of 70, and including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person".
第一項及び第二項の規定は、計算期間において当該保険者の被保険者であった者（基準日において他の健康保険の保険者の被保険者又はその被扶養者である者に限る。）に対する高額介護合算療養費の支給について準用する。この場合において、第一項中「第一号に掲げる額」とあるのは「第四項に規定する者が計算期間における当該保険者の被保険者であった間に、当該者が受けた療養（継続給付に係る療養を含む。）又はその被扶養者であった者がその被扶養者であった間に受けた療養（継続給付に係る療養を含む。）に係る第一号に規定する合算額」と、同項第一号中「基準日被保険者」とあるのは「他の健康保険の保険者の被保険者（基準日において当該他の健康保険の保険者の被保険者である者に限る。以下この項及び次項において「基準日被保険者」という。）」と、「保険者の」とあるのは「他の健康保険の保険者（以下この項において「基準日保険者」という。）の」と、同項第二号中「他の」とあるのは「基準日保険者以外の」と、同項第三号中「基準日被扶養者」とあるのは「基準日被保険者の被扶養者（基準日において基準日保険者の被保険者の被扶養者である者に限る。以下この項において「基準日被扶養者」という。）」と、「保険者の」とあるのは「基準日保険者の」と、同項第四号中「他の」とあるのは「基準日保険者以外の」と、第二項中「七十歳以上合算対象サービスに係る前項第一号に掲げる額」とあるのは「第四項に規定する者が計算期間における当該保険者の被保険者であった間に、当該者が受けた療養（七十歳に達する日の属する月の翌月以後に受けた療養に限り、継続給付に係る療養を含む。）又はその被扶養者であった者がその被扶養者であった間に受けた療養（七十歳に達する日の属する月の翌月以後に受けた療養に限り、継続給付に係る療養を含む。）に係る前項第一号に規定する合算額」と読み替えるものとする。
Expenses for high-cost medical treatment combined with long-term care for a person who was an insured person of the relevant insurer during the calculation period (limited to a person who, on the reference date, is a member, etc. (excluding a householder, etc. under National Health Insurance who is an insured person or a dependent thereof, and an insured person of the late-stage elderly medical care system) or a dependent, etc.) are to be paid where the amount (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care" in this paragraph) obtained by deducting the total payment for combined long-term care for persons aged 70 or over (meaning the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over under the following paragraph from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over prescribed in that paragraph (or zero, where that amount is equal to or less than the payment threshold or where the proviso to that paragraph applies to the calculation of that household total of co-payments, etc. combined with long-term care for persons aged 70 or over)) from the total sum of the amounts equivalent to the amounts listed in the items of paragraph (1) (hereinafter referred to as the "aggregated burden amount" in this paragraph and the following paragraph), calculated as provided by Order of the Ministry of Health, Labour and Welfare by deeming that member, etc. to be the insured person on the reference date and that dependent, etc. to be the dependent on the reference date, exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation, and the amount of those expenses is to be the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation from the household total of co-payments, etc. combined with long-term care by the apportionment rate for the combined long-term care calculation (meaning the rate obtained by dividing the amount obtained by deducting the amount of expenses for high-cost medical treatment combined with long-term care to be paid under the provisions of the following paragraph from the aggregated burden amount relating to medical treatment (including medical treatment under continued benefits) that the person prescribed in this paragraph received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person, by the household total of co-payments, etc. combined with long-term care); provided, however, that this does not apply where the total sum of the aggregated burden amounts relating to paragraph (1), items (i) through (v), or the total sum of the aggregated burden amounts relating to items (vi) and (vii) of that paragraph, is zero.
計算期間において当該保険者の被保険者であった者（基準日において組合員等（国民健康保険の世帯主等であって被保険者又はその被扶養者である者及び後期高齢者医療の被保険者を除く。）である者又は被扶養者等である者に限る。）に対する高額介護合算療養費は、当該組合員等である者を基準日被保険者と、当該被扶養者等である者を基準日被扶養者とそれぞれみなして厚生労働省令で定めるところにより算定した第一項各号に掲げる額に相当する額（以下この項及び次項において「通算対象負担額」という。）を合算した額から七十歳以上介護合算支給総額（次項に規定する七十歳以上介護合算一部負担金等世帯合算額から同項の七十歳以上介護合算算定基準額を控除した額（当該額が支給基準額以下である場合又は当該七十歳以上介護合算一部負担金等世帯合算額の算定につき同項ただし書に該当する場合には、零とする。）をいう。）を控除した額（以下この項において「介護合算一部負担金等世帯合算額」という。）が介護合算算定基準額に支給基準額を加えた額を超える場合に支給するものとし、その額は、介護合算一部負担金等世帯合算額から介護合算算定基準額を控除した額に介護合算按分率（この項に規定する者が計算期間における当該保険者の被保険者であった間に、当該者が受けた療養（継続給付に係る療養を含む。）又はその被扶養者であった者がその被扶養者であった間に受けた療養（継続給付に係る療養を含む。）に係る通算対象負担額から次項の規定により支給される高額介護合算療養費の額を控除した額を、介護合算一部負担金等世帯合算額で除して得た率をいう。）を乗じて得た額とする。ただし、第一項第一号から第五号までに係る通算対象負担額を合算した額又は同項第六号及び第七号に係る通算対象負担額を合算した額が零であるときは、この限りでない。
Where the total sum (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care for persons aged 70 or over" in this paragraph) of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare (hereinafter referred to as the "aggregated burden amount for persons aged 70 or over" in this paragraph) as amounts equivalent to those relating to services subject to combination for persons aged 70 or over, among the aggregated burden amounts, exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation for persons aged 70 or over, the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over by the apportionment rate for the combined long-term care calculation for persons aged 70 or over (meaning the rate obtained by dividing the aggregated burden amount for persons aged 70 or over relating to medical treatment (including medical treatment under continued benefits) that the person prescribed in the preceding paragraph received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person, by the household total of co-payments, etc. combined with long-term care for persons aged 70 or over) is to be paid as expenses for high-cost medical treatment combined with long-term care to the person prescribed in that paragraph; provided, however, that this does not apply where the total sum of the aggregated burden amounts for persons aged 70 or over relating to paragraph (1), items (i) through (v), or the total sum of the aggregated burden amounts for persons aged 70 or over relating to items (vi) and (vii) of that paragraph, is zero.
通算対象負担額のうち、七十歳以上合算対象サービスに係る額に相当する額として厚生労働省令で定めるところにより算定した額（以下この項において「七十歳以上通算対象負担額」という。）を合算した額（以下この項において「七十歳以上介護合算一部負担金等世帯合算額」という。）が七十歳以上介護合算算定基準額に支給基準額を加えた額を超える場合は、七十歳以上介護合算一部負担金等世帯合算額から七十歳以上介護合算算定基準額を控除した額に七十歳以上介護合算按分率（前項に規定する者が計算期間における当該保険者の被保険者であった間に、当該者が受けた療養（継続給付に係る療養を含む。）又はその被扶養者であった者がその被扶養者であった間に受けた療養（継続給付に係る療養を含む。）に係る七十歳以上通算対象負担額を、七十歳以上介護合算一部負担金等世帯合算額で除して得た率をいう。）を乗じて得た額を高額介護合算療養費として同項に規定する者に支給する。ただし、第一項第一号から第五号までに係る七十歳以上通算対象負担額を合算した額又は同項第六号及び第七号に係る七十歳以上通算対象負担額を合算した額が零であるときは、この限りでない。
Expenses for high-cost medical treatment combined with long-term care for a person who was an insured person of the relevant insurer during the calculation period (limited to a person who, on the reference date, is an insured person of the late-stage elderly medical care system) are to be paid where the total sum (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care" in this paragraph) of the amounts equivalent to the amounts listed in the items of paragraph (1), calculated as provided by Order of the Ministry of Health, Labour and Welfare by deeming that insured person of the late-stage elderly medical care system to be the insured person on the reference date (hereinafter referred to as the "aggregated burden amount" in this paragraph) exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation, and the amount of those expenses is to be the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation from the household total of co-payments, etc. combined with long-term care by the apportionment rate for the combined long-term care calculation (meaning the rate obtained by dividing the aggregated burden amount relating to medical treatment (including medical treatment under continued benefits) that the person prescribed in this paragraph received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person, by the household total of co-payments, etc. combined with long-term care); provided, however, that this does not apply where the total sum of the aggregated burden amounts relating to paragraph (1), items (i) through (v), or the total sum of the aggregated burden amounts relating to items (vi) and (vii) of that paragraph, is zero.
計算期間において当該保険者の被保険者であった者（基準日において後期高齢者医療の被保険者である者に限る。）に対する高額介護合算療養費は、当該後期高齢者医療の被保険者である者を基準日被保険者とみなして厚生労働省令で定めるところにより算定した第一項各号に掲げる額に相当する額（以下この項において「通算対象負担額」という。）を合算した額（以下この項において「介護合算一部負担金等世帯合算額」という。）が介護合算算定基準額に支給基準額を加えた額を超える場合に支給するものとし、その額は、介護合算一部負担金等世帯合算額から介護合算算定基準額を控除した額に介護合算按分率（この項に規定する者が計算期間における当該保険者の被保険者であった間に、当該者が受けた療養（継続給付に係る療養を含む。）又はその被扶養者であった者がその被扶養者であった間に受けた療養（継続給付に係る療養を含む。）に係る通算対象負担額を、介護合算一部負担金等世帯合算額で除して得た率をいう。）を乗じて得た額とする。ただし、第一項第一号から第五号までに係る通算対象負担額を合算した額又は同項第六号及び第七号に係る通算対象負担額を合算した額が零であるときは、この限りでない。
Read this with the articles around it
hospital, etc.machine translation
「病院等」
A hospital, clinic, pharmacy or other provider from which a person receives medical treatment.
Short name set inArticle 41, paragraph (1), item (i)
treatment subject to specified benefitsmachine translation
「特定給付対象療養」
Treatment for which the general medical expenses for atomic bomb survivors (原爆一般疾病医療費) under the Atomic Bomb Survivors' Assistance Act or another medical benefit a Ministry of Health, Labour and Welfare Order (厚生労働省令) names is to be given, and treatment for a disease needing very costly treatment over a very long period that the Minister of Health, Labour and Welfare designates, received by an insured person or dependent the insurer has certified under Article 41, paragraph (9).
Defined inArticle 41, paragraph (1), item (ii)
insured person of the late-stage elderly medical care systemmachine translation
「後期高齢者医療の被保険者」
An insured person of the late-stage elderly medical care system (後期高齢者医療) under Article 50 of the Act on Assurance of Medical Care for Elderly People.
Short name set inArticle 41, paragraph (4), item (i)
reference datemachine translation
「基準日」
The last day of the calculation period (計算期間), the period from 1 August each year to the following 31 July, on which high-cost medical expenses (高額療養費) and similar amounts for the whole period are worked out.
Defined inArticle 41-2, paragraph (1)
insured person on the reference datemachine translation
「基準日被保険者」
A person who, on the reference date (基準日), is an insured person (被保険者) of this insurer, other than a day-labour special insured person (日雇特例被保険者), a member of a mutual aid association (共済組合) under the National Public Officers Mutual Aid Association Act or the Local Public Officers, etc. Mutual Aid Association Act, or a participant in the mutual aid system under the Private School Personnel Mutual Aid Association Act.
Short name set inArticle 41-2, paragraph (1), item (i)
calculation periodmachine translation
「計算期間」
The period from 1 August each year to the following 31 July, over which annual amounts such as high-cost medical expenses (高額療養費) for outpatient treatment are worked out.
Defined inArticle 41-2, paragraph (4)
householder, etc. under National Health Insurancemachine translation
「国民健康保険の世帯主等」
The householder of a household that includes an insured person under National Health Insurance (国民健康保険), or a member of a National Health Insurance society (国民健康保険組合).
Short name set inArticle 41-2, paragraph (9)
medical treatment under continued benefitsmachine translation
「継続給付に係る療養」
In Article 41-3 and Article 43-2, medical treatment for which insurance benefits are given under Article 98, paragraph (1) of the Health Insurance Act (including as applied by Article 110, paragraph (7) and Article 111, paragraph (3)): the benefits that continue for treatment under way when a person loses insured status and becomes a day-labour special insured person (日雇特例被保険者) or the dependent of one.
Short name set inArticle 41-3, paragraph (1)· applies only in this provision and in Article 41-3, paragraph (2); and Article 43-2
medical treatment under the special rule on reaching age 75machine translation
「七十五歳到達時特例対象療養」
The medical treatment listed in the items of Article 41, paragraph (4): treatment received, in the month in which they joined the late-stage elderly medical care system (後期高齢者医療) on reaching age 75 on a day other than the first of the month (up to that day), by a person who thereby lost their health insurance coverage as an insured person (被保険者) or as a dependent (被扶養者), and by the former dependents of such an insured person who ceased to be dependents for that reason; for it, the thresholds this Order sets are halved, from 21,000 yen to 10,500 yen.
Short name set inArticle 41-3, paragraph (1), item (i)
household total of co-payments, etc. combined with long-term caremachine translation
「介護合算一部負担金等世帯合算額」
In Article 43-2, paragraph (1), the total of what the insured person on the reference date (基準日被保険者) and their dependents (被扶養者) bore over the calculation period (計算期間) for medical treatment — as insured persons or dependents of this or another health insurer, or of a mutual aid association or the like — and for in-home and preventive long-term care services, after the high-cost benefits already paid, less the amount paid for persons aged 70 or over (七十歳以上介護合算支給総額); where it exceeds the base amount for the combined long-term care calculation (介護合算算定基準額) plus the payment threshold (支給基準額), the medical share of the excess over that base amount is paid to that insured person as expenses for high-cost medical treatment combined with long-term care (高額介護合算療養費).
Short name set inArticle 43-2, paragraph (1)· applies only in this paragraph
payment thresholdmachine translation
「支給基準額」
In Article 43-2, the amount the Minister of Health, Labour and Welfare sets, having regard to the cost of handling payments of expenses for high-cost medical treatment combined with long-term care (高額介護合算療養費), by which a household's total must exceed the base amount before any such payment is made.
Short name set inArticle 43-2, paragraph (1)· applies only in this article
member, etc.machine translation
「組合員等」
A day-labour special insured person (日雇特例被保険者, including a former one who still holds a handbook with space left for health insurance stamps, with some exceptions), an insured person under Mariners Insurance, a member of a mutual aid association (共済組合) under the National Public Officers Mutual Aid Association Act or the Local Public Officers, etc. Mutual Aid Association Act, a participant in the mutual aid system under the Private School Personnel Mutual Aid Association Act, a householder, etc. under National Health Insurance (国民健康保険の世帯主等), or an insured person of the late-stage elderly medical care system (後期高齢者医療).
Defined inArticle 43-2, paragraph (1), item (v)· applies only in this item and in Article 43-2, paragraph (5)
dependent, etc.machine translation
「被扶養者等」
A dependent of a day-labour special insured person (日雇特例被保険者); a dependent under the Mariners Insurance Act, the National Public Officers Mutual Aid Association Act (including as other Acts apply it) or the Local Public Officers, etc. Mutual Aid Association Act; or an insured person under National Health Insurance (国民健康保険) in the same household as a householder, etc. under National Health Insurance (国民健康保険の世帯主等), other than that householder.
Defined inArticle 43-2, paragraph (1), item (v)· applies only in this item and in Article 43-2, paragraph (5)
in-home services, etc.machine translation
「居宅サービス等」
In Article 43-2, paragraphs (1) and (2), in-home services, etc. as defined in Article 22-2-2, paragraph (1) of the Cabinet Order for enforcing the Long-Term Care Insurance Act (介護保険法施行令).
Defined inArticle 43-2, paragraph (1), item (vi)· applies only in this provision and in Article 43-2, paragraph (2)
preventive long-term care services, etc.machine translation
「介護予防サービス等」
In Article 43-2, paragraphs (1) and (2), preventive long-term care services, etc. as defined in Article 22-2-2, paragraph (2) of the Cabinet Order for enforcing the Long-Term Care Insurance Act (介護保険法施行令).
Defined inArticle 43-2, paragraph (1), item (vii)· applies only in this provision and in Article 43-2, paragraph (2)
household total of co-payments, etc. combined with long-term care for persons aged 70 or overmachine translation
「七十歳以上介護合算一部負担金等世帯合算額」
In Article 43-2, paragraph (2), the part of the amounts listed in paragraph (1) — what a household bore over the calculation period (計算期間) for medical treatment and long-term care services — that relates to services received from the month after the month a person turns 70 (七十歳以上合算対象サービス), worked out as a Ministry of Health, Labour and Welfare Order (厚生労働省令) provides and added together; where it exceeds the base amount for the combined long-term care calculation for persons aged 70 or over (七十歳以上介護合算算定基準額) plus the payment threshold (支給基準額), the medical share of the excess over that base amount is paid to the insured person on the reference date (基準日被保険者) as expenses for high-cost medical treatment combined with long-term care (高額介護合算療養費).
Short name set inArticle 43-2, paragraph (2)· applies only in this paragraph
services subject to combination for persons aged 70 or overmachine translation
「七十歳以上合算対象サービス」
In Article 43-2, paragraphs (2) and (6), medical treatment, in-home services, etc. (居宅サービス等) or preventive long-term care services, etc. (介護予防サービス等) received from the month after the month the person turns 70.
Short name set inArticle 43-2, paragraph (2)· applies only in this paragraph and in Article 43-2, paragraph (6)
insurer on the reference datemachine translation
「基準日保険者」
In Article 41-2, paragraphs (3) and (4) and Article 43-2, paragraph (4), the other health insurer that, on the reference date (基準日), covers a person who was this insurer's insured person during the calculation period (計算期間), as its insured person or as the dependent of one.
Short name set inArticle 43-2, paragraph (4)· applies only in this paragraph
insured person on the reference datemachine translation
「基準日被保険者」
In Article 43-2, paragraphs (4) and (5), on expenses for high-cost medical treatment combined with long-term care (高額介護合算療養費) for a person who was this insurer's insured person during the calculation period (計算期間) but on the reference date (基準日) is covered by another health insurer, an insured person of that other health insurer who is its insured person on the reference date.
Short name set inArticle 43-2, paragraph (4)· applies only in this paragraph and in Article 43-2, paragraph (2)
dependent on the reference datemachine translation
「基準日被扶養者」
A dependent (被扶養者) of the insured person on the reference date (基準日被保険者) who is still such a dependent on the reference date (基準日); in Article 43-2, paragraph (4), one who on that date is the dependent of an insured person of the other health insurer then covering them (基準日保険者).
Short name set inArticle 43-2, paragraph (4)· applies only in this paragraph
household total of co-payments, etc. combined with long-term caremachine translation
「介護合算一部負担金等世帯合算額」
In Article 43-2, paragraph (5), for a person who was this insurer's insured person during the calculation period (計算期間) but on the reference date (基準日) belongs to a mutual aid association or the like (組合員等) or is the dependent of one, the total of the aggregated burden amounts (通算対象負担額) worked out for them, less the amount paid for persons aged 70 or over (七十歳以上介護合算支給総額); where it exceeds the base amount for the combined long-term care calculation (介護合算算定基準額) plus the payment threshold (支給基準額), the share of the excess over that base amount relating to their time with this insurer is paid to them as expenses for high-cost medical treatment combined with long-term care (高額介護合算療養費).
Short name set inArticle 43-2, paragraph (5)· applies only in this paragraph
aggregated burden amountmachine translation
「通算対象負担額」
In Article 43-2, paragraphs (5) and (6), for a person who was this insurer's insured person during the calculation period (計算期間) but on the reference date (基準日) is a member, etc. (組合員等) of another scheme or a dependent, etc. (被扶養者等) of one, the amounts corresponding to those in paragraph (1) — what the household bore for medical treatment and long-term care services — worked out as a Ministry of Health, Labour and Welfare Order (厚生労働省令) provides by treating the member as the insured person on the reference date and the dependent as the dependent on the reference date.
Short name set inArticle 43-2, paragraph (5)· applies only in this paragraph and in Article 43-2, paragraph (6)
household total of co-payments, etc. combined with long-term care for persons aged 70 or overmachine translation
「七十歳以上介護合算一部負担金等世帯合算額」
In Article 43-2, paragraph (6), the total of the aggregated burden amounts for persons aged 70 or over (七十歳以上通算対象負担額) of a person who was this insurer's insured person during the calculation period (計算期間) but on the reference date (基準日) belongs to a mutual aid association or the like; where it exceeds the base amount for the combined long-term care calculation for persons aged 70 or over (七十歳以上介護合算算定基準額) plus the payment threshold (支給基準額), the share of the excess over that base amount relating to the time with this insurer is paid to that person as expenses for high-cost medical treatment combined with long-term care (高額介護合算療養費).
Short name set inArticle 43-2, paragraph (6)· applies only in this paragraph
aggregated burden amount for persons aged 70 or overmachine translation
「七十歳以上通算対象負担額」
In Article 43-2, paragraph (6), the part of the aggregated burden amount (通算対象負担額) that relates to services received from the month after the month a person turns 70 (七十歳以上合算対象サービス), worked out as a Ministry of Health, Labour and Welfare Order (厚生労働省令) provides.
Short name set inArticle 43-2, paragraph (6)· applies only in this paragraph
household total of co-payments, etc. combined with long-term caremachine translation
「介護合算一部負担金等世帯合算額」
In Article 43-2, paragraph (7), for a person who was this insurer's insured person during the calculation period (計算期間) but on the reference date (基準日) is an insured person of the late-stage elderly medical care system (後期高齢者医療), the total of the aggregated burden amounts (通算対象負担額) worked out for them; where it exceeds the base amount for the combined long-term care calculation (介護合算算定基準額) plus the payment threshold (支給基準額), the share of the excess over that base amount relating to their time with this insurer is paid to them as expenses for high-cost medical treatment combined with long-term care (高額介護合算療養費).
Short name set inArticle 43-2, paragraph (7)· applies only in this paragraph
aggregated burden amountmachine translation
「通算対象負担額」
In Article 43-2, paragraph (7), for a person who was this insurer's insured person during the calculation period (計算期間) but on the reference date (基準日) is an insured person of the late-stage elderly medical care system (後期高齢者医療), the amounts corresponding to those in paragraph (1) — what the household bore for medical treatment and long-term care services — worked out as a Ministry of Health, Labour and Welfare Order (厚生労働省令) provides by treating that person as the insured person on the reference date.
Short name set inArticle 43-2, paragraph (7)· applies only in this paragraph