Article 54-3Special Medical Expenses

①In the case where a Householder who is in arrears with insurance premiums (limited to a Householder who has a domicile within the area of the Municipality) or a Society member who is in arrears with insurance premiums (excluding a Householder or Society member all of whose insured persons belonging to the household are able to receive payment of general medical expenses under the Atomic Bomb Survivors' Assistance Act (Act No. 117 of 1994) or other benefits relating to medical care specified by Order of the Ministry of Health, Labour and Welfare (referred to as "payment of general medical expenses for atomic bomb survivors, etc." in this paragraph and paragraph (4)); hereinafter referred to as a "householder, etc. in arrears with insurance premiums" in this Article) still does not pay those insurance premiums during the period until the period specified by Order of the Ministry of Health, Labour and Welfare has elapsed from the due date for payment of those insurance premiums even though the Municipality or Society concerned has taken measures contributing to payment of insurance premiums specified by Order of the Ministry of Health, Labour and Welfare, such as encouraging payment of those insurance premiums and ensuring opportunities for consultation on payment of those insurance premiums (referred to as "encouragement of insurance premium payment, etc." in the following paragraph and Article 63-2, paragraphs (1) and (2)), then, except where it is found that there are special circumstances specified by Cabinet Order, such as a disaster, in the arrears of those insurance premiums, when an insured person belonging to that household (excluding persons able to receive payment of general medical expenses for atomic bomb survivors, etc. and persons in the period until the first March 31 on or after the day on which they reach the age of 18; the same applies hereinafter in this Article (excluding paragraphs (4) and (5))) receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider, Municipalities and Societies are to pay special medical expenses to the householder, etc. in arrears with insurance premiums with respect to the expenses incurred in that medical treatment or designated home nursing, in lieu of benefits for medical treatment or payment of expenses for Dietary Treatment for inpatients, etc. (meaning expenses for Dietary Treatment for inpatients, Living Support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses or medical expenses for home-nursing; the same applies in paragraphs (4) and (5)) (referred to as "Benefits for Medical Treatment, etc." in the following paragraph and paragraph (5)).

③When paying special medical expenses pursuant to the provisions of paragraph (1) or the main clause of the preceding paragraph, Municipalities and Societies are to notify in advance the householder, etc. in arrears with insurance premiums, as provided by Order of the Ministry of Health, Labour and Welfare, that special medical expenses will be paid when an insured person belonging to the household receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider.

④In the case where a householder, etc. in arrears with insurance premiums who is subject to the application of paragraph (1) or the main clause of paragraph (2) has paid the arrears of insurance premiums in full, or where it is found that there are special circumstances specified by Cabinet Order, such as a significant decrease in the amount in arrears pertaining to that person or a disaster, or where an insured person belonging to that household has become a person able to receive payment of general medical expenses for atomic bomb survivors, etc., when an insured person belonging to the household of the Householder or Society member who falls under these cases (in the case where an insured person belonging to the household of that householder, etc. in arrears with insurance premiums has become a person able to receive payment of general medical expenses for atomic bomb survivors, etc., limited to that insured person; the same applies hereinafter in this paragraph and the following paragraph) receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider, Municipalities and Societies are to provide benefits for medical treatment to the insured person belonging to the household of that Householder or Society member, or pay expenses for Dietary Treatment for inpatients, etc. to that Householder or Society member.

⑤When providing benefits for medical treatment or paying expenses for Dietary Treatment for inpatients, etc. pursuant to the provisions of the preceding paragraph, Municipalities and Societies are to notify in advance the Householder or Society member who falls under the case prescribed in that paragraph, as provided by Order of the Ministry of Health, Labour and Welfare, that Benefits for Medical Treatment, etc. will be provided when an insured person belonging to the household receives medical treatment from a health insurance-covered medical institution, etc. or receives designated home nursing from a designated home-nursing provider.

⑥The provisions of Article 64 of the Health Insurance Act and paragraph (3) of Article 36, Articles 40 and 41, paragraph (3) of Article 45, Article 45-2, paragraph (5) of Article 52, paragraph (2) of Article 53, paragraphs (3), (8) and (10) of Article 54-2, Article 54-2-2 and the preceding Article of this Act shall apply mutatis mutandis to medical treatment or designated home nursing covered by special medical expenses received at or from a health insurance-covered medical institution, etc. or a designated home-nursing provider and to the payment of special medical expenses associated with such medical treatment or designated home nursing. In this case, the phrase "The amount of medical expenses combined with treatment outside insurance coverage" in Article 53, paragraph (2) shall be deemed to be replaced with "The amount of special medical expenses" and the phrase "Article 86, paragraph (2), item (i) of the Health Insurance Act" in that paragraph shall be deemed to be replaced with "Article 76, paragraph (2) of the Health Insurance Act in the case where benefits for medical treatment can be received, those prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 86, paragraph (2), item (i) of the same Act in the case where payment of medical expenses combined with treatment outside insurance coverage can be received, or those prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 88, paragraph (4) of the same Act in the case where payment of medical expenses for home-nursing can be received", and any technical replacement of terms necessary for the other provisions shall be specified by Cabinet Order.

⑦When the provisions of Article 54, paragraph (1) would apply to an insured person belonging to the household of a householder, etc. in arrears with insurance premiums who is subject to the application of paragraph (1) or the main clause of paragraph (2) if the insured person were not subject to the application of those provisions, Municipalities and Societies may pay medical expenses.

⑧Where an insured person belonging to the household of a householder, etc. in arrears with insurance premiums who is subject to the application of paragraph (1) or the main clause of paragraph (2) has received any medical care or medication at or from a health insurance-covered medical institution, etc. without receiving confirmation of being an insured person by electronic eligibility confirmation, etc., and when it is found that the failure to receive such confirmation was due to an emergency situation or any other unavoidable reason, Municipalities and Societies shall pay medical expenses.

⑨The provisions of Article 54, paragraphs (3) and (4) shall apply mutatis mutandis to the medical expenses under the preceding two paragraphs. In this case, the phrase "shall be received" in paragraph (4) of that Article shall be deemed to be replaced with "can be received".