Articles 45-4 to 46, Chapter VII Sharing of Costs — Order for Enforcement of the Health Insurance Act

3 articles

Article 45-4Adjustment of Finances for Health Insurance on the Basis of a Single Branch-Insured Person

第四十五条の四（支部被保険者を単位とする健康保険の財政の調整）

The adjustment of finances for health insurance on the basis of a single branch-insured person that is carried out pursuant to the provisions of Article 160, paragraph (4) of the Act is to be age adjustment and financial capability adjustment.

法第百六十条第四項の規定により行う支部被保険者を単位とする健康保険の財政の調整は、年齢調整及び財政力調整とする。

The age adjustment referred to in the preceding paragraph is to be carried out, in accordance with the classification of cases listed in the following items, as specified respectively in those items.

前項の年齢調整は、次の各号に掲げる場合の区分に応じ、当該各号に定めるところにより行うものとする。

in the case where the branch age-adjusted standard benefit cost is the branch average benefit cost or more: to deduct the amount obtained by deducting that branch average benefit cost from that branch age-adjusted standard benefit cost;

支部年齢勘案標準給付費額が支部平均給付費額以上である場合　当該支部年齢勘案標準給付費額から当該支部平均給付費額を控除した額を控除すること。

in the case where the branch age-adjusted standard benefit cost is less than the branch average benefit cost: to add the amount obtained by deducting that branch age-adjusted standard benefit cost from that branch average benefit cost.

支部年齢勘案標準給付費額が支部平均給付費額未満である場合　当該支部平均給付費額から当該支部年齢勘案標準給付費額を控除した額を加算すること。

The financial capability adjustment referred to in paragraph (1) is to be carried out, in accordance with the classification of cases listed in the following items, as specified respectively in those items.

第一項の財政力調整は、次の各号に掲げる場合の区分に応じ、当該各号に定めるところにより行うものとする。

in the case where the branch benefit cost apportioned by total remuneration is the branch average benefit cost or more: to add the amount obtained by deducting that branch average benefit cost from that branch benefit cost apportioned by total remuneration;

支部総報酬按分給付費額が支部平均給付費額以上である場合　当該支部総報酬按分給付費額から当該支部平均給付費額を控除した額を加算すること。

in the case where the branch benefit cost apportioned by total remuneration is less than the branch average benefit cost: to deduct the amount obtained by deducting that branch benefit cost apportioned by total remuneration from that branch average benefit cost.

支部総報酬按分給付費額が支部平均給付費額未満である場合　当該支部平均給付費額から当該支部総報酬按分給付費額を控除した額を控除すること。

In the preceding two paragraphs, the meanings of the terms listed in the following items are as prescribed respectively in those items.

前二項において、次の各号に掲げる用語の意義は、当該各号に定めるところによる。

"branch age-adjusted standard benefit cost" means the total sum of the amounts obtained, for each age group, as specified by Order of the Ministry of Health, Labour and Welfare, by multiplying the average benefit per person by age group relating to that age group (meaning the amount obtained, as specified by Order of the Ministry of Health, Labour and Welfare, by dividing the amount obtained by deducting, from the estimated amount of expenses required in the business year following the business year (meaning the business year following the business year prescribed in Article 45-2 and, where the premium rate for each prefecture is calculated pursuant to the preceding Article, the business year to which the month of application prescribed in that Article belongs; the same applies hereinafter in this paragraph) for the benefits for medical treatment, etc. relating to insured persons of health insurance administered by JHIA and their dependents belonging to that age group, the estimated total sum of the amount equivalent to the partial co-payment payable pursuant to the provisions of the Act out of that estimated amount and the amount of national subsidy pursuant to the provisions of Article 153 of the Act, by the estimated total number of insured persons of health insurance administered by JHIA and their dependents belonging to that age group in the business year following the business year) by the estimated total number of the branch-insured person concerned and the dependents of that person belonging to that age group in the business year following the business year;

支部年齢勘案標準給付費額　厚生労働省令で定めるところにより、年齢階級ごとに、当該年齢階級に係る年齢階級別平均一人当たり給付額（厚生労働省令で定めるところにより、療養の給付等のうち協会が管掌する健康保険の被保険者及びその被扶養者であって当該年齢階級に属する者に係るものについて当該一の事業年度の翌事業年度（第四十五条の二に規定する当該一の事業年度の翌事業年度をいい、前条の規定に基づき都道府県単位保険料率を算定する場合にあっては、同条に規定する当該適用月の属する事業年度をいう。以下この項において同じ。）に要する費用の見込額から当該見込額のうち法の規定により支払うべき一部負担金に相当する額及び法第百五十三条の規定による国庫補助の額の合算額の見込額を控除した額を、当該一の事業年度の翌事業年度において協会が管掌する健康保険の被保険者及びその被扶養者であって当該年齢階級に属する者の合計数の見込数で除して得た額をいう。）に当該一の事業年度の翌事業年度において当該支部被保険者及びその被扶養者であって当該年齢階級に属する者の合計数の見込数を乗じて得た額を合算した額をいう。

"branch average benefit cost" means the amount obtained by multiplying, as specified by Order of the Ministry of Health, Labour and Welfare, the average benefit per person (meaning the amount obtained, as specified by Order of the Ministry of Health, Labour and Welfare, by dividing the amount obtained by deducting, from the estimated amount of expenses required in the business year following the business year for the benefits for medical treatment, etc. relating to insured persons of health insurance administered by JHIA and their dependents, the estimated total sum of the amount equivalent to the partial co-payment payable pursuant to the provisions of the Act out of that estimated amount and the amount of national subsidy pursuant to the provisions of Article 153 of the Act (referred to as the "estimated total benefit cost" in the following item), by the estimated total number of insured persons of health insurance administered by JHIA and their dependents in the business year following the business year) by the estimated total number of the branch-insured person concerned and the dependents of that person in the business year following the business year;

支部平均給付費額　厚生労働省令で定めるところにより、平均一人当たり給付額（厚生労働省令で定めるところにより、療養の給付等のうち協会が管掌する健康保険の被保険者及びその被扶養者に係るものについて当該一の事業年度の翌事業年度に要する費用の見込額から当該見込額のうち法の規定により支払うべき一部負担金に相当する額及び法第百五十三条の規定による国庫補助の額の合算額の見込額を控除した額（次号において「総給付費見込額」という。）を、当該一の事業年度の翌事業年度における協会が管掌する健康保険の被保険者及びその被扶養者の合計数の見込数で除して得た額をいう。）に当該一の事業年度の翌事業年度における当該支部被保険者及びその被扶養者の合計数の見込数を乗じて得た額をいう。

"branch benefit cost apportioned by total remuneration" means the amount obtained by multiplying, as specified by Order of the Ministry of Health, Labour and Welfare, the estimated total benefit cost by the estimated value of the total remuneration proportion ratio prescribed in Article 160, paragraph (3), item (ii) of the Act in the business year following the business year.

支部総報酬按分給付費額　厚生労働省令で定めるところにより、総給付費見込額に当該一の事業年度の翌事業年度における法第百六十条第三項第二号に規定する総報酬按分率の見込値を乗じて得た額をいう。

Article 45-5Upper Limit of the Children and Child-Rearing Support Contribution Rate

第四十五条の五（子ども・子育て支援金率の上限）

The rate specified by Cabinet Order as referred to in Article 160-2, paragraph (1) of the Act is 2.5/1,000.

法第百六十条の二第一項の政令で定める率は、千分の二・五とする。

Article 46Accumulation of Reserves

第四十六条（準備金の積立て）

JHIA must, at the end of each business year, accumulate the amount of surplus of that business year as a reserve until it reaches the sum of the amount equivalent to one-twelfth of the average per business year of the amount of expenses required for insurance benefits provided in that business year and the two business years immediately preceding it (including the amount of expenses required for payment of young-old payments, etc., aid for the old-old, etc., and day laborer contributions, long-term care payments, and contributions for securing medical care in the early phase of an epidemic, etc. (where there is a young-old subsidy, the amount after deducting it), and excluding the amount of childbirth and childcare grants and the amount of national subsidies pursuant to the provisions of Articles 153 and 154 of the Act), and the amount determined by the Minister of Health, Labour and Welfare in consultation with the Prime Minister, within a range not exceeding the amount equivalent to one-twelfth of the amount of expenses required for payment of the children and child-rearing support levy made in that business year, taking into account the expenses required for the payment of the children and child-rearing support levy by insurers in that year.

協会は、毎事業年度末において、当該事業年度及びその直前の二事業年度内において行った保険給付に要した費用の額（前期高齢者納付金等、後期高齢者支援金等及び日雇拠出金、介護納付金並びに流行初期医療確保拠出金等の納付に要した費用の額（前期高齢者交付金がある場合には、これを控除した額）を含み、出産育児交付金の額並びに法第百五十三条及び第百五十四条の規定による国庫補助の額を除く。）の一事業年度当たりの平均額の十二分の一に相当する額並びに当該事業年度において行った子ども・子育て支援納付金の納付に要した費用の額の十二分の一に相当する額を超えない範囲内において当該年度における保険者の子ども・子育て支援納付金の納付に要する費用を勘案して厚生労働大臣が内閣総理大臣と協議して定める額とを合算した額に達するまでは、当該事業年度の剰余金の額を準備金として積み立てなければならない。

A health insurance society must, at the end of each business year, accumulate the amount of surplus of that business year as a reserve until it reaches the sum of the amount equivalent to three-twelfths of the average per business year of the amount of expenses required for insurance benefits provided in that business year and the two business years immediately preceding it (excluding the amount of expenses required for insurance benefits relating to medical treatment that an insured person or the dependent of that person received from a hospital, clinic, or pharmacy listed in Article 63, paragraph (3), item (iii) of the Act, and the amount of childbirth and childcare grants), the amount equivalent to one-twelfth of the average per business year of the amount of expenses required for payment of young-old payments, etc., aid for the old-old, etc., and day laborer contributions, long-term care payments, and contributions for securing medical care in the early phase of an epidemic, etc. provided in that business year and the two business years immediately preceding it (where there is a young-old subsidy, the amount after deducting it), and the amount determined by the Minister of Health, Labour and Welfare in consultation with the Prime Minister, within a range not exceeding the amount equivalent to one-twelfth of the amount of expenses required for payment of the children and child-rearing support levy made in that business year, taking into account the expenses required for the payment of the children and child-rearing support levy by insurers in that year.

健康保険組合は、毎事業年度末において、当該事業年度及びその直前の二事業年度内において行った保険給付に要した費用の額（被保険者又はその被扶養者が法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受けた療養に係る保険給付に要した費用の額及び出産育児交付金の額を除く。）の一事業年度当たりの平均額の十二分の三に相当する額と当該事業年度及びその直前の二事業年度内において行った前期高齢者納付金等、後期高齢者支援金等及び日雇拠出金、介護納付金並びに流行初期医療確保拠出金等の納付に要した費用の額（前期高齢者交付金がある場合には、これを控除した額）の一事業年度当たりの平均額の十二分の一に相当する額並びに当該事業年度において行った子ども・子育て支援納付金の納付に要した費用の額の十二分の一に相当する額を超えない範囲内において当該年度における保険者の子ども・子育て支援納付金の納付に要する費用を勘案して厚生労働大臣が内閣総理大臣と協議して定める額とを合算した額に達するまでは、当該事業年度の剰余金の額を準備金として積み立てなければならない。

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