Act on Assurance of Medical Care for Elderly People (Tentative translation)
Table of Contents
Chapter I General Provisions (Articles 1 through 7)
Chapter II Promotion of Appropriate Medical Expenses
Section 1 Plans for Regulating Medical Expenses (Articles 8 through 17-2)
Section 2 Basic Guidelines on Special health examinations (Articles 18 to 31)
Chapter III Coordination of Sharing of Expenses between Insurers Pertaining to Young-Old Persons (Articles 32 to 46)
Chapter IV Late-Stage Elderly Medical Care System
Section 1 General Provisions (Articles 47 through 49)
Section 2 Insured (Articles 50 through 55-2)
Section 3 Old-Old Age medical care benefit
Subsection 1 General Rules (Articles 56 through 63)
Subsection 2 Benefits for Medical Treatment and Payment of Dietary Treatment Expenses for Inpatients
Division 1 Benefits for Medical Treatment, and Payment of Dietary Treatment Expenses for Inpatients, Living Support Expenses for Inpatients, Medical Expenses Combined with Treatment Outside Insurance Coverage, and Medical Expenses (Articles 64 through 77)
Division 2 Payment of Medical Expenses for Home-Nursing (Articles 78 through 81)
Division 3 Payment of Special Medical Expenses (Article 82)
Division 4 Payment of Transport Expenses (Article 83)
Subsection 3 Payment of High-Cost Medical Expenses and Sizable medical and nursing expenses (Articles 84 and 85)
Subsection 4 Other Late-Stage medical care benefit for the Elderly (Article 86)
Subsection 5 Restrictions on Late-Stage medical care benefit for the Elderly (Articles 87 through 92)
Section 4 Expenses
Subsection 1 Bearing of Expenses (Articles 93 through 115)
Subsection 2 Fiscal Stability Fund (Article 116)
Subsection 3 Special high medical care cost Joint Enterprise (Article 117)
Subsection 4 Medical Care Assistance for the Elderly Aged 75 and over of Insurers (Articles 118 through 124)
Subsection 5 Childbirth and Childcare Support Benefits of Association of Medical Care Systems for the Elderly Aged 75 and older (Articles 124-2 through 124-8)
Subsection 6 Miscellaneous Provisions (Article 124-9)
Section 5 Healthcare Services for the Elderly (Articles 125 through 125-4)
Section 6 Examination Committee for Medical Fees for Old-Old Healthcare (Articles 126 and 127)
Section 7 Request for Examination (Articles 128 through 130)
Section 8 Assistance for Healthcare Services for the Elderly (Articles 131 and 132)
Section 9 Miscellaneous Provisions (Articles 133 through 138)
Chapter V Services Related to the Medical Care System for the Elderly at the Health Insurance Claims Review & Reimbursement Services (Articles 139 through 154)
Chapter VI Medical Services for the Elderly of the National Health Insurance Federation (Articles 155 through 157)
Chapter VII Miscellaneous Provisions (Articles 157-2 through 166)
Chapter VIII Penal Provisions (Articles 167 through 171)
Supplementary Provisions
Chapter I General Provisions
(Purpose)
Article 1  The purpose of this Act is to formulate a plan for promoting the optimization of medical expenses and to take measures for the implementation of health checkups, etc. by insurers in order to ensure appropriate medical care for the citizens in their old age, and with regard to medical care for the elderly, to establish a system necessary for adjusting the sharing of expenses between insurers pertaining to the young-old and for providing appropriate medical care benefits, etc. for the old-old, based on the principle of joint and several action by citizens, thereby improving the health of the citizens and promoting the welfare of the elderly.
(Basic Principles)
Article 2  (1) Citizens, based on the spirit of self-help and solidarity, are to endeavor at all times to maintain and improve their health, being conscious of the mental and physical changes that occur as a result of aging, and to bear the expenses required for medical care for elderly persons in a fair manner.
(2) Citizens are to be given the opportunity to receive appropriate health services to help maintain their health in old age, in accordance with their age, mental and physical condition, etc., at work, in the community, or at home.
(Responsibilities of the State)
Article 3  The national government must take all necessary measures to ensure the smooth implementation of efforts to ensure the appropriateness of the expenses required for medical care by citizens in old age and the sound operation of the medical insurance system for the elderly (meaning the adjustment of the sharing of expenses among insurers pertaining to the young-old provided for in Chapter III and the medical insurance system for the old-old provided for in Chapter IV; the same applies hereinafter), and actively promote medical care, public health, social welfare, and other related measures in order to contribute to the achievement of the purpose provided for in Article 1.
(Responsibilities of Local Governments)
Article 4  (1) A local government must respect the purport of this Act and implement the necessary measures to ensure that efforts are made to ensure the appropriateness of the expenses required for medical care by residents in old age and the management of the medical care system for the elderly is carried out appropriately and smoothly.
(2) In efforts to ensure the optimization of expenses required for medical care by residents in old age as prescribed in the preceding paragraph, the prefecture is to play a central part in obtaining the cooperation of Insurers, the Association of Medical Care Systems for the Elderly Aged 75 and older prescribed in Article 48 (referred to as the "Association of Medical Care Systems for the Elderly Aged 75 and older" in Articles 8 through 16 and Article 27), medical personnel, and other relevant persons, in light of its responsibility to ensure the medical care delivery system (meaning the medical care delivery system prescribed in Article 30-3, paragraph (1) of the Medical Care Act (Act No. 205 of 1948)) in the prefecture and the sound operation of national health insurance services by the prefecture and municipalities (including special wards; the same applies hereinafter) within the prefecture.
(Responsibilities of Insurers)
Article 5  An insurer must endeavor to actively promote the services necessary for maintaining the health of its members in old age, and must cooperate so that the operation of the medical care system for the elderly is implemented in a sound and smooth manner.
(Responsibilities of Medical Care Professionals)
Article 6  Physicians, dentists, pharmacists, nurses, and other medical care professionals, as well as the organizers and administrators of medical institutions prescribed in Article 1-2, paragraph (2) of the Medical Care Act, must cooperate with the various measures, policies, and undertakings prescribed in the preceding three Articles.
(Definitions)
Article 7  (1) The term "Medical Insurance Acts" as used in this Act means the following acts:
(i) the Health Insurance Act (Act No. 70 of 1922);
(ii) the Mariners Insurance Act (Act No. 73 of 1939);
(iii) the National Health Insurance Act (Act No. 192 of 1958);
(iv) national Public Officers' mutual aid association Act (Act No. 128 of 1958);
(v) local public employee and Harbor mutual aid association Act (Act No. 152 of 1962);
(vi) private School Teachers Mutual Aid Association Act (Act No. 245 of 1953).
(2) The term "Insurers" as used in this Act means Japan Health Insurance Association, health insurance societies, prefectures and municipalities, national health insurance societies, mutual aid association, or the Promotion and Mutual Aid Corporation for Private Schools of Japan, which provide medical care benefits pursuant to the provisions of the Medical Insurance Acts.
(3) The term "insurers of health insurance, etc." as used in this Act means insurers (excluding Japan Health Insurance Association, prefectural and municipal governments, and national health insurance societies as insurers under the provisions of Article 123, paragraph (1) of the employee insurance Act) or national health insurance societies whose members are persons who do not become insured under the same Act with the approval under the provisions of Article 3, paragraph (1), item (viii) of the Health Insurance Act, as specified by the Minister of Health, Labour and Welfare.
(4) The term "participant" as used in this Act means the following persons:
(i) a insured pursuant to the provisions of the Health Insurance Act; provided, however, that this does not apply to a specially-permitted insured for day laborers pursuant to the provisions of Article 3, paragraph (2) of the same Act;
(ii) a insured under the provisions of the Mariners Insurance Act;
(iii) a insured pursuant to the provisions of the National Health Insurance Act;
(iv) a member of a mutual aid association based on the National Public Officers mutual aid association Act or the local public employee, etc. mutual aid association Act;
(v) a member of the Private School Teachers mutual aid system under the provisions of the Private School Teachers Mutual Aid Act;
(vi) a dependent pursuant to the provisions of the Health Insurance Act, the Mariners Insurance Act, the National Public Officers mutual aid association Act (including as applied mutatis mutandis pursuant to other Acts), or the local public employee mutual aid association Act; provided, however, that this does not apply to a dependent pursuant to the provisions of the Health Insurance Act of a specially-insured day laborer insured pursuant to the provisions of Article 3, paragraph (2) of the same Act;
(vii) a person who has received a specially-insured day laborer insured card pursuant to the provisions of Article 126 of the Health Insurance Act and has not run out of blank space for stamps for proof of health insurance in the card, and a dependent of the person pursuant to the provisions of the same Act; provided, however, that this does not apply to a person who has received approval pursuant to the provisions of the proviso to Article 3, paragraph (2) of the same Act and is within a period during which the person is not eligible to be a specially-insured day laborer insured pursuant to the provisions of the same paragraph, a person who has returned the specially-insured day laborer Article 126, paragraph (3) card pursuant to the provisions of insured of the same Act, and a dependent of the person pursuant to the provisions of the same Act.
Chapter II Promotion of Appropriate Medical Expenses
Section 1 Plans to Optimize Medical Expenses
(Basic Policy for Regulating Medical Expenses and National Plan for Regulating Medical Expenses)
Article 8  (1) From the perspective of ensuring appropriate medical care for the people in old age, in order to promote the optimization of expenses required for medical care (hereinafter referred to as "optimization of medical expenses") in a comprehensive and systematic manner, the Minister of Health, Labour and Welfare is to establish basic policies concerning measures for the optimization of medical expenses (hereinafter referred to as the "basic policies for the optimization of medical expenses"), and establish a plan for promoting the optimization of medical expenses every six years (hereinafter referred to as the "national plan for the optimization of medical expenses") with six years as one period.
(2) The Basic Policy on Regulating Medical Expenses is to provide for the following matters:
(i) the standards to be taken into consideration pertaining to the targets to be specified in the Prefectural Plan for Regulating Medical Expenses as prescribed in paragraph (1) of the following Article and other basic matters to be guidelines in preparing the plan;
(ii) basic matters concerning the evaluation of the degree of achievement of the prefectural plan for regulating medical expenses prescribed in paragraph (1) of the following Article;
(iii) basic particulars concerning investigation and analysis of the expenses required for medical services;
(iv) beyond what is set forth in the preceding three items, important matters concerning the promotion of the optimization of medical expenses.
(3) The basic policies for regulating medical expenses must be in harmony with the basic policies prescribed in Article 30-3, paragraph (1) of the Medical Care Act, the basic guidelines prescribed in the Article 116, paragraph (1) of the Long-Term Care Insurance Act (Act No. 123 of 1997), and the basic policies prescribed in Article 7, paragraph (1) of the Health Promotion Act (Act No. 103 of 2002).
(4) The National Plan for Regulating Medical Expenses is to specify the following matters:
(i) the particulars of the goals that the national government must achieve to advance the optimization of medical expenses in connection with the furtherance of the people's commitment to maintaining their health;
(ii) with regard to the promotion of the efficient provision of medical care, matters concerning the targets to be achieved by the national government for the promotion of the optimization of medical expenses;
(iii) matters concerning measures to be taken by the national government in order to achieve the goals set forth in the preceding two items;
(iv) particulars concerning coordination and cooperation among insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions, and other relevant persons in order to achieve the goals set forth in items (i) and (ii);
(v) in light of the implementation of projects based on the medical care plan (meaning the medical care plan prescribed in Article 30-4, paragraph (1) of the Medical Care Act; the same applies hereinafter) of each prefecture, matters concerning the results of the promotion of the differentiation and coordination of the bed functions (meaning the bed functions prescribed in Article 30-3, paragraph (2), item (vi) of the same Act; the same applies hereinafter) expected during the period of the plan;
(vi) matters concerning the prospective expenses required for medical care during the period of the plan calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, based on the matters set forth in the preceding item, the expected effects of the optimization of medical expenses through the promotion of the maintenance of citizens' health and the promotion of the efficient provision of medical care to achieve the goals set forth in items (i) and (ii), and other matters specified by Order of the Ministry of Health, Labour and Welfare (referred to as the "national target of expenses required for medical care" in Article 11, paragraph (7));
(vii) matters concerning the evaluation of the status of the achievement of the plan;
(viii) beyond what is set forth in the preceding items, matters necessary for promoting the optimization of medical expenses.
(5) In specifying the particulars set forth in items (i) through (iii) of the preceding paragraph, the Minister of Health, Labour and Welfare is to pay attention to the significance of efforts towards the establishment of a community-based integrated care system prescribed in Article 2, paragraph (1) of the Act on the Promotion of Differentiation and Coordination of the Bed's Functions and the Comprehensive Securing of Medical Care and Nursing Care in Local Communities (Act No. 64 of 1989) (referred to as the "community-based integrated care system" in paragraph (4) of the following Article) and the effective and efficient provision of medical care and nursing care in light of the physical, mental and social characteristics of the citizens as they age.
(6) The Minister of Health, Labour and Welfare is to consult with the head of a relevant administrative organ in advance, when intending to establish or change the Basic Policies for Regulating Medical Expenses or the National Plan for Regulating Medical Expenses.
(7) When the Minister of Health, Labour and Welfare has established or revised the Basic Policies for Ensuring Appropriate Medical Expenses and the National Plan for Ensuring Appropriate Medical Expenses, the Minister is to publicize this without delay.
(8) The Minister of Health, Labour and Welfare may request necessary cooperation from insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions, and other relevant persons, when the Minister finds it necessary for the preparation of the national plan for regulating medical expenses and the implementation of measures based on the national plan for regulating medical expenses.
(Prefectural Plan for Regulating Medical Expenses)
Article 9  (1) A prefecture is to establish a plan to promote the optimization of medical expenses in the prefecture (hereinafter referred to as the "prefectural plan for the optimization of medical expenses") every six years, with six years as one period, in line with the basic policy for the optimization of medical expenses.
(2) The Prefectural Plan for Regulating Medical Expenses is to provide for the following matters:
(i) with regard to the promotion of the maintenance of residents' health, matters concerning targets to be achieved for the promotion of the optimization of medical expenses in the prefecture;
(ii) with regard to the promotion of the efficient provision of medical care, matters concerning targets to be achieved for the promotion of the optimization of medical expenses in the relevant prefecture;
(iii) particulars concerning the results of the promotion of the differentiation and coordination of the bed functions expected during the period of the plan, based on the implementation of the project under the medical care plan of the relevant prefecture;
(iv) matters concerning the prospective expenses required for medical care during the plan period calculated pursuant to the provisions of Prefectural Order of the Ministry of Health, Labour and Welfare, based on the matters set forth in the preceding item and the effects of the optimization of medical expenses that are expected to be achieved by promoting the maintenance of residents' health and promoting the efficient provision of medical care in order to achieve the goals set forth in item (i) and item (ii) (referred to as the "prefectural target for expenses required for medical care" in Article 11, paragraph (4)).
(3) In addition to the matters prescribed in the preceding paragraph, a prefectural plan for regulating medical expenses is to, in general, provide for the following matters concerning the prefecture:
(i) matters concerning measures to be taken by the prefecture in order to achieve the goals set forth in items (i) and (ii) of the preceding paragraph;
(ii) particulars concerning coordination and cooperation among insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions, and other relevant persons in order to achieve the goals set forth in items (i) and (ii) of the preceding paragraph;
(iii) particulars concerning the investigation and analysis of the expenses required for medical services in the prefecture;
(iv) matters concerning the evaluation of the status of the achievement of the plan.
(4) In specifying the particulars set forth in paragraph (2), items (i) and (ii) and item (i) of the preceding paragraph, the prefecture is to pay attention to the importance of promoting the differentiation and coordination of the bed functions in the region, efforts towards the construction of a community-based integrated care system, and the effective and efficient provision of medical care and nursing care in light of the physical, mental and social characteristics of residents as they age.
(5) A prefecture, in providing for the particulars set forth in paragraph (3), item (iii), is to take into consideration the expenses required for medical services in a prefecture other than the relevant prefecture and other particulars specified by Order of the Order of the Ministry of Health, Labour and Welfare.
(6) A prefectural plan for regulating medical expenses must be in harmony with the medical care plan, the prefectural insured long-term care services plan as prescribed in Article 118, paragraph (1), Long-Term Care Insurance Act, and the prefectural health promotion plan as prescribed in Article 8, paragraph (1) of the Health Promotion Act.
(7) When a prefecture intends to formulate or revise a prefectural plan for regulating medical expenses, it must consult with the council of insurers of the relevant municipality and Article 157-2, paragraph (1) (referred to as the "council of insurers" in paragraph (10) and Article 12, paragraph (1)) in advance.
(8) When a prefecture has formulated or revised its prefectural plan for regulating medical expenses, it is to endeavor to publicize the plan and submit it to the Minister of Health, Labour and Welfare without delay.
(9) A prefecture may request necessary cooperation from Insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions, and other relevant persons when it finds it necessary for the preparation of a Prefectural Plan for Regulating Medical Expenses and the implementation of measures based on the Prefectural Plan for Regulating Medical Expenses.
(10) If a prefecture requests necessary cooperation from insurers or Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the preceding paragraph, the prefecture may request the cooperation through the council of insurers.
(Advice of the Minister of Health, Labour and Welfare)
Article 10  The Minister of Health, Labour and Welfare may provide a prefecture with necessary advice on methods for formulating a prefectural plan for optimization of medical expenses and other important technical matters for formulating a prefectural plan for optimization of medical expenses.
(Publication of the Progress of Plans)
Article 11  (1) A prefecture is to endeavor to publicize the state of progress of the prefectural plan for regulating medical expenses in each fiscal year (meaning the period from April 1 of each year to March 31 of the following year; the same applies hereinafter) (excluding the fiscal year in which the results under the following paragraph were publicized and the evaluation set forth in paragraph (1) of the following Article was conducted) pursuant to the provisions of Prefectural Order of the Ministry of Health, Labour and Welfare.
(2) In order to contribute to the preparation of the Prefectural Plan for Regulating Medical Expenses in the next term, the prefecture is to endeavor to publicize the results of surveys and analyses on the state of progress of the Prefectural Plan for Regulating Medical Expenses during the plan period (hereinafter referred to as the "Plan Period" in this paragraph and paragraph (4)) in the fiscal year that includes the end date of the Prefectural Plan for Regulating Medical Expenses, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(3) In order to contribute to the preparation of the Basic Policies for Regulating Medical Expenses, when a prefecture has conducted the investigation and analysis set forth in the preceding paragraph, it is to endeavor to report the results to the Minister of Health, Labour and Welfare pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(4) If a prefecture finds that the goals set forth in Article 9, paragraph (2), items (i) and (ii) cannot be achieved during the plan period, or that the expenses required for medical care in the prefecture significantly exceed the target expenses required for medical care by the prefecture, the prefecture is to analyze the causes of this, and endeavor to take necessary measures in cooperation with insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions, and other relevant persons to eliminate the causes.
(5) The Minister of Health, Labour and Welfare is to publicize the status of progress of the national plan for regulating medical expenses in each fiscal year (excluding the fiscal year in which the results under the following paragraph were publicized and the evaluation referred to in paragraph (3) of the following Article was conducted) pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare.
(6) In order to contribute to the preparation of the national medical expense optimization plan for the next term, the Minister of Health, Labour and Welfare is to publicize the results of the investigation and analysis of the national medical expense optimization plan during the plan period (hereinafter referred to as the "plan period" in this paragraph and the following paragraph) in the fiscal year that includes the end date of the plan period, pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare.
(7) If the Minister of Health, Labour and Welfare finds that the goals set forth in Article 8, paragraph (4), items (i) and (ii) cannot be achieved during the plan period, or that the expenses required for medical care by the national government significantly exceed the target expenses required for medical care by the national government, the Minister is to analyze the causes of this, and take necessary measures to resolve the causes in cooperation with insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions, and other relevant parties.
(Evaluation of Plan Performance)
Article 12  (1) A prefecture, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare, in the fiscal year following the fiscal year that includes the last day of the period of the Prefectural Plan for Regulating Medical Expenses, is to investigate and analyze the status of achievement of the objectives of the plan and the status of implementation of measures, hear the opinions of the Council of Insurers, and evaluate the performance of the plan.
(2) When the prefectural government has conducted the evaluation referred to in the preceding paragraph, the prefectural government is to endeavor to make the results public and report them to the Minister of Health, Labour and Welfare pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(3) In the fiscal year following the fiscal year that includes the last day of the period of the National Plan for Regulating Medical Expenses, the Minister of Health, Labour and Welfare is to investigate and analyze the status of the achievement of the objectives of the plan and the status of the implementation of measures, and evaluate the results of the plan, as well as evaluate the results of the Prefectural Plan for Regulating Medical Expenses in each prefecture by hearing the opinions of the prefectures concerned based on the report set forth in the preceding paragraph, as specified by Order of the Ministry of Health, Labour and Welfare.
(4) When the Minister of Health, Labour and Welfare conducts the evaluation referred to in the preceding paragraph, the Minister is to publicize the results of the evaluation.
(Submission of Opinions on Medical Fees)
Article 13  (1) If a prefecture finds it necessary for achieving the goals set forth in Article 9, paragraph (2), item (ii) as a result of the evaluation referred to in paragraph (1) of the preceding Article, the prefecture may submit to the Minister of Health, Labour and Welfare its opinions on the provisions under Article 76, paragraph (2) of the Health Insurance Act, the provisions under Article 88, paragraph (4) of the same Act, the standards for calculating the amount of expenses required for benefits for medical treatment provided in Article 71, paragraph (1), and the standards specified by the Minister of Health, Labour and Welfare provided in Article 78, paragraph (4) (referred to as "medical fees" in the following paragraph and paragraph (1) of the following Article).
(2) When the prefectural government submits its opinions pursuant to the provisions of the preceding paragraph, the Minister of Health, Labour and Welfare must endeavor to determine the medical fees in consideration of the opinions.
(Special Provisions for Medical Fees)
Article 14  (1) If, as a result of the evaluation referred to in Article 12, paragraph (3), the Minister of Health, Labour and Welfare finds it necessary for achieving the goals set forth in Article 8, paragraph (4), item (ii) and in Article 9, paragraph (2), item (ii) in each prefecture and for promoting the optimization of medical expenses, the Minister may specify medical fees in the areas of one prefecture that are different from those in the areas of other prefectures, within a scope that is found to be reasonable from the viewpoint of providing appropriate medical care fairly among the prefectures, while taking into account the actual conditions of the area.
(2) In establishing the provisions of the preceding paragraph, the Minister of Health, Labour and Welfare is to consult with the relevant prefectural governors in advance.
(Cooperation and Advice on the Submission of Materials)
Article 15  (1) If the Minister of Health, Labour and Welfare or the prefectural governor finds it necessary to make public the status of progress referred to in Article 11, paragraph (1) or (5) or the results referred to in paragraph (2) or (6) of the same Article, or to make the evaluation referred to in Article 12, paragraph (1) or (3), the Minister or the governor may request cooperation from insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions, and other relevant persons for the submission of necessary materials.
(2) The Minister of Health, Labour and Welfare and the prefectural governor may provide necessary advice or assistance to insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, or medical institutions based on the progress made public pursuant to the provisions of Article 11, paragraph (1) or paragraph (5), the results referred to in paragraph (2) or paragraph (6) of the same Article, or the results of the evaluation referred to in Article 12, paragraph (1) or paragraph (3).
(Investigation and Analysis for the Preparation of Plans for Regulating Medical Expenses)
Article 16  (1) The Minister of Health, Labour and Welfare is to investigate and analyze data concerning the following particulars (hereinafter referred to as "medical insurance-related data"), and publicize the results thereof, for the purpose of contributing to the preparation, implementation, and evaluation of the national plan for regulating medical expenses and the prefectural plan for regulating medical expenses:
(i) the status of expenses required for medical care by area, age group, or disease, and other particulars specified by Order of the Order of the Ministry of Health, Labour and Welfare;
(ii) the status of changes in the number of beds concerning the provision of medical care by area and other particulars specified by the Order of the Ministry of Health, Labour and Welfare.
(2) Insurers and Association of Medical Care Systems for the Elderly Aged 75 and older must provide medical insurance-related information to the Minister of Health, Labour and Welfare by a method specified by Order of the Ministry of Health, Order of the Ministry of Health, Labour and Welfare, Japan.
(3) The Minister of Health, Labour and Welfare, when finding it necessary, may request a prefecture, municipality, or any other person specified by Order of the Order of the Ministry of Health, Labour and Welfare to provide medical insurance-related information by a method specified by Order of the Order of the Ministry of Health, Labour and Welfare.
(Use or Provision of Anonymized Medical Data to Improve People's Health)
Article 16-2  (1) In order to contribute to the improvement of the health of the people, the Minister of Health, Labour and Welfare may use anonymized medical data (meaning medical insurance-related information that has been processed in accordance with the standards specified by Prefectural or Municipal Order of the Ministry of Health, Labour and Welfare in order to make it impossible to identify a specific insured or any other Order of the Ministry of Health, Labour and Welfare specified by Prefectural or Municipal Order of the Ministry of Health, Labour and Welfare pertaining to medical insurance-related information (hereinafter referred to as the "identifiable person" in the following Article) and to restore the medical insurance-related information used to create the identifiable person; the same applies hereinafter), or, pursuant to the provisions of Prefectural or Municipal Ordinance, provide the anonymized medical data to a person set forth in one of the following items who performs the services specified in the relevant item as services that are found to have a considerable public interest if they are provided with anonymized medical data:
(i) other national administrative organs and local governments: surveys concerning the planning and drafting of policies that contribute to the provision of appropriate health and medical services;
(ii) universities and other research institutes: research on the causes of diseases and methods of prevention, diagnosis, and treatment of diseases, and other research on the improvement and promotion of public health;
(iii) private business operators and other persons specified by Order of the Ministry of Health, Labour and Welfare: analyses that contribute to research and development in the medical field and other services specified by Order of the Ministry of Health, Labour and Welfare (excluding those carried out for the purpose of using them in the advertisement or promotion of specific goods or services).
(2) An Minister of Health, Labour and Welfare, when using or providing information pursuant to the provisions of the preceding paragraph, may use the anonymized medical data, etc. in a way that links it to anonymized medical data, etc. provided for in Article 150-2, paragraph (1) of the Health Insurance Act, anonymized long-term care insurance data, etc. provided for in Article 118-3, paragraph (1), Long-Term Care Insurance Act, and other data specified by Order of the Order of the Ministry of Health, Labour and Welfare, or provide the anonymized medical data, etc. in a way that allows it to be used in a way that links it to other data.
(3) If the Minister of Health, Labour and Welfare intends to provide anonymized medical data pursuant to the provisions of paragraph (1), the Minister must hear the opinion of the Social Security Council in advance.
(Prohibition of Collation)
Article 16-3  A person who receives and uses anonymized medical data, etc. pursuant to the provisions of paragraph (1) of the preceding Article (hereinafter referred to as a "user of anonymized medical data, etc. related information"), in handling the anonymized medical data, etc. related information, in order to identify the principal pertaining to the medical insurance related information used to prepare the anonymized medical data, etc. related information, must not obtain information on descriptions, etc. (meaning any and all matters stated or recorded in a document, drawing, or electronic or magnetic record (meaning a record made in an electronic or magnetic form (meaning an electronic form, a magnetic form, or any other form that cannot be recognized by human perception)), or expressed by using sound, motion, or any other method) deleted from the medical insurance related information or information on the processing method used to prepare the anonymized medical data, etc. related information, or cross-check the anonymized medical data, etc. related information with other information.
(Deletion)
Article 16-4  When a user of anonymized medical data, etc. no longer needs to use the provided anonymized medical data, etc., the user must delete the anonymized medical data, etc. without delay.
(Safety Management Measures)
Article 16-5  Users of anonymized medical data must take measures specified by Order of the Order of the Ministry of Health, Labour and Welfare as necessary and appropriate for the security control of the anonymized medical data, such as the prevention of leakage, loss, or damage to the anonymized medical data.
(Obligations of Users)
Article 16-6  A person who is or was a user of anonymized medical data related to medical insurance, etc. must not disclose the anonymized medical data related to medical insurance, etc. acquired in relation to the use of the anonymized medical data related to medical insurance, etc. to other persons without justifiable grounds or use the anonymized medical data related to medical insurance, etc. for an unjust purpose.
(On-Site Inspections)
Article 16-7  (1) To the extent necessary for the enforcement of the provisions of this Section, the Minister of Health, Labour and Welfare may order users of anonymized medical data (excluding other administrative organs of the national government; hereinafter the same applies in this paragraph and the following Article) to make a report or submit or present books and documents, or have the relevant officials question the relevant persons or enter the offices or other places of business of the users of anonymized medical data to inspect the books, documents, and any other articles of the users of anonymized medical data.
(2) When carrying out questioning or on-site inspections under the provisions of the preceding paragraph, the relevant officials must carry an identification card and present it when requested by any person concerned.
(3) The authority under the provisions of paragraph (1) must not be construed as being granted for the purpose of criminal investigation.
(Rectification Order)
Article 16-8  When the Minister of Health, Labour and Welfare finds that a user of anonymized medical data is in violation of any of the provisions of Articles 16-3 through 16-6, the Minister of Health, Labour and Welfare may order the person to take necessary measures to rectify the violation.
(Entrustment to the Payment Fund)
Article 17  The Minister of Health, Labour and Welfare may entrust the investigation and analysis prescribed in Article 16, paragraph (1) and the affairs pertaining to the use or provision under Article 16-2, paragraph (1), in whole or in part, to the Health Insurance Claims Review & Reimbursement Services under the Health Insurance Claims Review & Reimbursement Services Act (Act No. 129 of 1948) (hereinafter referred to as the "Reimbursement Services"), the National Health Insurance Federation prescribed in Article 45, paragraph (5) of the National Health Insurance Act (hereinafter referred to as the "NHI Federations"), or other persons specified by Order of the Ministry of Health, Labour and Welfare (referred to as the "Reimbursement Services, etc." in the following Article).
(Fees)
Article 17-2  (1) Users of anonymized medical data must pay a fee in the amount specified by Cabinet Order in consideration of the actual costs to the national government (when the payment fund, etc. conducts all of the affairs related to the provision of anonymized medical data under Article 16-2, paragraph (1) upon entrustment from the Minister of Health, Labour and Welfare pursuant to the provisions of the preceding Article, the payment fund, etc.).
(2) If a person who intends to pay the fee set forth in the preceding paragraph is a prefecture or any other person specified by Cabinet Order as a person who plays particularly important roles in improving the health of the people, the Minister of Health, Labour and Welfare may grant the person a reduction of or exemption from the fee pursuant to the provisions of Cabinet Order.
(3) The fees paid to the payment fund, etc. pursuant to the provisions of paragraph (1) are the income of the payment fund, etc.
Section 2 Basic Guidelines for Special health examinations
(Basic Guidelines for Special health examinations)
Article 18  (1) The Minister of Health, Labour and Welfare is to establish basic guidelines for the appropriate and effective implementation of Special health examinations (meaning health checkups for diabetes and other lifestyle diseases specified by Cabinet Order; the same applies hereinafter) and specified health guidance (meaning health guidance given to a person specified by Order of the Order of the Ministry of Health, Labour and Welfare as one who needs to endeavor to maintain their health based on the results of a Special health examinations by a person specified by Order of the Order of the Ministry of Health, Labour and Welfare as one who has expert knowledge and skills concerning health guidance; the same applies hereinafter) (hereinafter referred to as the "basic guidelines for Special health examinations, etc.").
(2) The Basic Guidelines on Special health examinations, etc. are to provide for the following matters:
(i) basic matters concerning the implementation method of Special health examinations and specified health guidance (hereinafter referred to as "Special health examinations, etc.");
(ii) basic matters concerning the goals pertaining to the implementation of a Special health examinations, etc. and the results thereof;
(iii) beyond what is set forth in the preceding two items, important matters concerning the preparation of a Special health examinations plan provided in paragraph (1) of the following Article.
(3) The Basic Guidelines on Special health examinations, etc. must be harmonized with the Guidelines on Health Checkups, etc. provided for in Article 9, paragraph (1) of the Health Promotion Act.
(4) When the Minister of Health, Labour and Welfare intends to establish or change the basic guidelines for Special health examinations, etc., the Minister is to consult with the head of the relevant administrative organ in advance.
(5) When the Minister of Health, Labour and Welfare has established or changed the basic guidelines for Special health examinations, etc., the Minister is to publicize the established or changed guidelines without delay.
(Special health examinations Implementation Plan)
Article 19  (1) In line with the Basic Guidelines for Special health examinations, etc., Insurers (or Municipalities, in the case of National Health Insurance provided by a prefecture together with the Municipalities within the relevant prefecture pursuant to the provisions of the National Health Insurance Act (hereinafter referred to as "National Health Insurance"); the same applies hereinafter in this Section and in Article 125-3, paragraphs (1) and (4)) are to establish a plan for the implementation of Special health examinations, etc. (hereinafter referred to as the "Implementation Plan for Special health examinations, etc.") every six years, with six years as one period.
(2) The Special health examinations plan is to specify the following matters:
(i) matters concerning the specific implementation method of the Special health examinations, etc.;
(ii) specific goals related to the implementation and outcomes of the Special health examinations, etc.;
(iii) beyond what is set forth in the preceding two items, matters necessary for the appropriate and effective implementation of Special health examinations, etc.
(3) When providing or changing the Special health examinations implementation plan, insurers must make it public without delay.
(Special health examinations)
Article 20  Insurers are to provide Special health examinations to subscribers who are 40 years of age or older pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare based on the implementation plan for Special health examinations, etc.; provided, however, that this does not apply when a subscriber has undergone a health checkup equivalent to an Special health examinations and has received a document certifying the results or when a record concerning an Special health examinations has been sent pursuant to the provisions of Article 26, paragraph (2).
(Relationship with Medical Examinations Based on Other Laws and Regulations)
Article 21  (1) If a member has undergone or is eligible to undergo a medical examination equivalent to a Special health examinations conducted pursuant to the Industrial Safety and Health Act (Act No. 57 of 1972) or other laws and orders, the insurer is to be the person who has undergone all or part of the Special health examinations referred to in the preceding Article pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare.
(2) An employer prescribed in Article 2, item (iii) of the Industrial Safety and Health Act or any other person responsible for conducting medical examinations equivalent to Special health examinations pursuant to laws and orders (hereinafter referred to as an "employer, etc.") may entrust the implementation of the medical examinations to insurers. In this case, the employer, etc. that intends to entrust the implementation of the medical examinations must pay the necessary expenses to the insurers.
(Preservation of Records Concerning Special health examinations)
Article 22  When having conducted a Special health examinations pursuant to the provisions of Article 20, Insurers must maintain the records of the Special health examinations pursuant to the provisions of Prefectural or Municipal Order of the Ministry of Health, Labour and Welfare. The same applies when having received documents certifying the results of the Special health examinations or sent the records of the Special health examinations pursuant to the provisions of the proviso to the same Article, or when having received a copy of the records of the Special health examinations, the health checkup prescribed in the Article 125, paragraph (1), or the medical checkup pursuant to the provisions of Article 27, paragraph (4).
(Notice of Special health examinations Results)
Article 23  Insurers, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare, must notify a member who has undergone an Special health examinations of the results of the Special health examinations. The same applies where records concerning the Special health examinations have been sent pursuant to the provisions of Article 26, paragraph (2).
(Specific Health Guidance)
Article 24  Insurers are to provide specified health guidance pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare based on the implementation plan for Special health examinations, etc.
(Preservation of Records Concerning Specific Health Guidance)
Article 25  When providing specified health guidance pursuant to the provisions of the preceding Article, Insurers must maintain records concerning the specified health guidance pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare. The same applies when receiving records concerning specified health guidance pursuant to the provisions of paragraph (2) of the following Article or when receiving a copy of records concerning specified health guidance or health guidance provided by Article 125, paragraph (1) pursuant to the provisions of Article 27, paragraph (4).
(Special health examinations for Subscribers of Other Insurers)
Article 26  (1) An Insurer may, if it does not hinder the implementation of Special health examinations, etc. for its Subscribers, provide Special health examinations or Specific Health Guidance pertaining to the Subscribers of other Insurers. In this case, the Insurer may, pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare, claim the expenses required for the Special health examinations or Specific Health Guidance from the person who received the Special health examinations or Specific Health Guidance.
(2) If an Insurer provides Special health examinations or Specific Health Guidance to a member of another Insurer pursuant to the provisions of the preceding paragraph, it must promptly send the records concerning the Special health examinations or Specific Health Guidance to the other Insurer which the member is currently enrolled in, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(3) If a member of an Insurer receives Special health examinations or Specific Health Guidance provided by another Insurer pursuant to the provisions of paragraph (1) and pays the expenses thereof to the other Insurer, the Insurer pays a reasonable amount of money to the member as expenses required for the Special health examinations or Specific Health Guidance pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare.
(4) Notwithstanding the provisions of paragraph (1) and the preceding paragraph, an Insurer may, upon consultation with other Insurers, specify otherwise with regard to the treatment of claims and payments of expenses for Special health examinations or Specific Health Guidance pertaining to the Subscribers of the other Insurers.
(Provision of Records Concerning Special health examinations)
Article 27  (1) For the purpose of ensuring the appropriate and effective implementation of Special health examinations, etc., when there is a person who has acquired the status of a Participant (in the case of national health insurance, including a insured whose address has been changed from the area of another Municipality within the same prefecture; the same applies in the following paragraph), Insurers may request other Insurers to which the relevant Participant belonged to provide copies of records concerning Special health examinations or Specific Health Guidance pertaining to the relevant Participant which the relevant other Insurers have preserved.
(2) For the purpose of ensuring the appropriate and effective implementation of Special health examinations, etc., when a person who has acquired the eligibility as a member was eligible to be a insured of a Association of Medical Care Systems for the Elderly Aged 75 and older in the past, insurers may request the Association of Medical Care Systems for the Elderly Aged 75 and older to provide a copy of the record kept by the Association of Medical Care Systems for the Elderly Aged 75 and older concerning the health checkups or health guidance prescribed in the Article 125, paragraph (1) pertaining to the member.
(3) In order to ensure the appropriate and effective implementation of Special health examinations, etc., insurers may, pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare, request employers, etc. (including those specified by Order of Order of the Ministry of Health, Labour and Welfare; hereinafter the same applies in this paragraph and the following paragraph) that employ or used to employ subscribers to provide copies of records concerning medical examinations pertaining to the relevant subscribers that are kept by the relevant employers, etc. pursuant to the Industrial Safety and Health Act and other laws and orders, or other documents specified by Order of Order of the Ministry of Health, Labour and Welfare as being equivalent thereto.
(4) Other Insurers, Association of Medical Care Systems for the Elderly Aged 75 and older, or Employers, etc. that have been requested, pursuant to the provisions of the preceding three paragraphs, to provide copies of records concerning Special health examinations or Specific Health Guidance, records concerning Health Checkups or Health Guidance provided for in Article 125, paragraph (1), or records concerning medical examinations kept on file pursuant to the Industrial Safety and Health Act or other laws and orders must provide copies of the records as specified by Order of Order of the Ministry of Health, Labour and Welfare.
(Entrustment of Implementation)
Article 28  Insurers may entrust the implementation of Special health examinations, etc., to hospitals or clinics listed in each item of Article 63, paragraph (3) of the Health Insurance Act or others that are found to be appropriate. In this case, Insurers may provide copies of records on Special health examinations or specific health guidance that they maintain and other necessary information to the trustee to the extent necessary for the implementation of Special health examinations, etc., to be entrusted, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(Coordination with Relevant Parties)
Article 29  (1) In providing Special health examinations, etc. to subscribers who are young-old as prescribed in Article 32, paragraph (1), insurers are to pay attention to appropriate coordination with municipalities that provide community support projects pursuant to the provisions of Article 115-45, paragraphs (1) and (2), Long-Term Care Insurance Act, while taking into account the mental and physical characteristics of subscribers who are young-old, and are to endeavor to ensure the efficient implementation of the Special health examinations, etc.
(2) Beyond what is provided for in the preceding paragraph, Insurers must endeavor to cooperate with other Insurers, medical institutions, and other relevant persons for the efficient implementation of Special health examinations.
(Scope of Persons Eligible for Special health examinations Administered by a Municipality)
Article 29-2  A municipality set forth in Article 3, paragraph (1) of the National Health Insurance Act is to perform the affairs under the provisions of this Section with regard to a insured that has an address within the area of the municipality.
(duty of confidentiality)
Article 30  A person who has been entrusted with the implementation of Special health examinations, etc., by Insurers pursuant to the provisions of Article 28 (if the person is a corporation, its officers) or its employees, or a person who used to be any of these persons must not, without justifiable grounds, divulge any personal secrets that have come to their knowledge in the course of the implementation.
(Harmonization with the Health Checkup Guidelines)
Article 31  A Order of the Ministry of Health, Labour and Welfare prescribed in Article 18, paragraph (1), Article 20, Article 21, paragraph (1), Articles 22 through 25, Article 26, paragraph (2), Article 27, paragraphs (3) and (4), and Article 28 must be in harmony with the health checkup guidelines prescribed in Article 9, paragraph (1) of the Health Promotion Act.
Chapter III Coordination of Sharing of Expenses between Insurers Pertaining to Young-Old Persons
(Young-Old Subsidies)
Article 32  (1) The Payment Fund, pursuant to the provisions of Cabinet Order, is to provide Insurers with Young-Old Grants in order to adjust the imbalances in the burden related to the percentage of the number of Subscribers who are Young-Old Age (meaning Subscribers who reach 65 years of age in the month following the month in which they reach 65 years of age (if that day is the first day of the month, the month in which that day falls) and who reach 75 years of age before the month in which they reach 75 years of age, and other persons specified by Order of the Ministry of Health, Labour and Welfare; the same applies hereinafter) in the number of Subscribers of each of the Insurers (or prefectural governments in the case of national health insurance; hereinafter the same applies in this Chapter).
(2) Young-Old Payments collected by the Payment Fund pursuant to the provisions of Article 36, paragraph (1) are allocated to the Young-Old Subsidy referred to in the preceding paragraph.
(Amount of the Young-Old Subsidy)
Article 33  (1) The amount of the Young-Old Subsidy to be granted to each Insurer pursuant to the provisions of paragraph (1) of the preceding Article is the estimated amount of the Young-Old Subsidy for the relevant fiscal year; provided, however, that when the estimated amount of the Young-Old Subsidy for the fiscal year before the previous fiscal year exceeds the fixed amount of the Young-Old Subsidy for the same fiscal year, the amount of the Young-Old Subsidy is to be the amount obtained by subtracting the sum of the excess amount and the Young-Old Grant Adjustment Amount pertaining to the excess amount from the estimated amount of the Young-Old Subsidy for the relevant fiscal year, and when the estimated amount of the Young-Old Subsidy for the fiscal year before the previous fiscal year is less than the fixed amount of the Young-Old Subsidy for the same fiscal year, the amount of the Young-Old Subsidy is to be the amount obtained by adding the estimated amount of the Young.
(2) The Young-Old Subsidy Adjustment Amount prescribed in the preceding paragraph is the amount calculated for each of the Insurers pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare by taking into consideration the interest arising from the difference between the estimated amount of the Young-Old Subsidy and the fixed amount of the Young-Old Subsidy pertaining to all of the Insurers in the fiscal year before the previous fiscal year and other circumstances.
(Estimated Young-Old Subsidies)
Article 34  (1) The estimated amount of the Young-Old Subsidy referred to in paragraph (1) of the preceding Article is the amount specified in the following items in accordance with the category of Insurer set forth in each of those items:
(i) insurers of employee insurance, etc.: the sum of the amounts listed in (a) and (b):
(a) the amount equivalent to two-thirds of the amount obtained by subtracting the amount set forth in 3. from the sum of the amounts set forth in 1. and 2. (if the amount is less than zero, it is deemed to be zero):
1. the estimated amount of benefits expenses subject to adjustment pertaining to the insurer in the relevant fiscal year;
2. the amount obtained by multiplying the amount obtained by dividing the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over of the Article 119, paragraph (1) pertaining to the relevant insurer in the relevant fiscal year by the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over adjustment rate set forth in the items of Article 120, paragraph (1) pertaining to the relevant insurer in the same fiscal year by the rate calculated for each of the insurers based on the ratio of the prospective number of subscribers who are young-old to the prospective number of subscribers pertaining to the relevant insurer in the same fiscal year (hereinafter referred to as the "estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to young-old");
3. the estimated base amount subject to adjustment in the relevant fiscal year;
(b) the amount equivalent to one third of the amount obtained by deducting the estimated base amount for adjustment after adjustment of remunerations in the relevant fiscal year from the sum of the estimated amount of benefit expenses subject to adjustment pertaining to the insurer and the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old in the relevant fiscal year (if the amount is less than zero, it is deemed to be zero);
(ii) insurers other than insurers covered by employee insurance, etc.: the amount obtained by deducting the estimated base amount for adjustment in the relevant fiscal year from the sum of the estimated amount of benefit expenses subject to adjustment pertaining to the relevant insurers and the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old in the relevant fiscal year (if the amount is less than zero, it is deemed to be zero).
(2) The estimated amount of benefits expenses subject to adjustment referred to in the items of the preceding paragraph is the amount obtained by multiplying the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the average of the estimated average per person amount of benefits expenses subject to adjustment (meaning the amount obtained by dividing the amount obtained by deducting the amount set forth in item (ii) from the amount set forth in item (i) in each fiscal year by the estimated number of subscribers who are young-old adults pertaining to the insurer in each fiscal year calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare) pertaining to the insurer in each fiscal year of the relevant fiscal year, the fiscal year preceding the relevant fiscal year, and the fiscal year before the fiscal year preceding the relevant fiscal year by the estimated number of subscribers who are young-old adults pertaining to the insurer in the relevant fiscal year calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare:
(i) the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the amount pertaining to subscribers who are young-old among the prospective amount of expenses required for benefits of the relevant insurers (in the case of national health insurance, benefits of municipalities within a prefecture) which fall under those specified by Order of the Ministry of Health, Labour and Welfare among benefits concerning medical care pursuant to the provisions of medical insurance acts (excluding other benefits prescribed in Article 53 of the Health Insurance Act and benefits equivalent thereto) (hereinafter referred to as "expenses required for benefits by insurers") (hereinafter referred to as "prospective amount of young-old benefit expenses");
(ii) the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the portion of the prospective Young-Old Benefit pertaining to the Insurers if the Insurers are Insurers in Excess of the Estimated Standard (meaning Insurers for which the rate obtained by dividing the amount set forth in (a) by the amount set forth in (b) exceeds the rate specified by Cabinet Order in consideration of the distribution, etc. of the prospective Young-Old Benefit per participant who is a Young-Old Person pertaining to all Insurers), which exceeds the amount obtained by multiplying the amount set forth in (b) by the rate specified by Cabinet Order:
(a) the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the prospective amount of young-old benefit expenses per Participant who is a young-old pertaining to a single Insurer;
(b) the estimated average per person of young-old benefit expenses.
(3) The estimated base amount subject to adjustment set forth in the items of paragraph (1) is the amount obtained by multiplying the sum of the estimated amount of benefit expenses subject to adjustment set forth in the items of the same paragraph pertaining to the relevant insurer and the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old (in the case of an insurer of employee insurance, etc., the amount obtained by multiplying the relevant amount by the estimated amount adjustment rate) by the estimated participant adjustment rate.
(4) The base amount for adjustment after adjustment of estimated compensation referred to in paragraph (1), item (i), (b) is the amount obtained by multiplying the estimated amount of payment expenses subject to adjustment set forth in the items of the same paragraph pertaining to the insurer by the rate obtained by dividing the amount set forth in item (i) in the relevant fiscal year by the amount set forth in item (ii) (referred to as the "estimated compensation adjustment rate" in paragraph (6), item (i)) and the estimated benefit expense adjustment rate, and by the estimated participant adjustment rate, the sum of the amounts obtained by multiplying the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old by the estimated amount adjustment rate:
(i) the amount obtained by dividing the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the prospective amount of the total amount of standardized remunerations pertaining to the insurer (referred to as the "prospective amount of the total amount of standardized remunerations" in the following item and Article 120, paragraph (1), item (i), (a) and (b)) by the prospective number of subscribers pertaining to the insurer calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare;
(ii) the amount calculated pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare as the amount obtained by dividing the sum of the prospective amounts of the total amount of standardized remunerations pertaining to all Insurers of employee insurance, etc. by the prospective total number of subscribers pertaining to all Insurers of employee insurance, etc.
(5) The estimated amount correction rate referred to in the preceding two paragraphs is the rate calculated pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare so that the sum of the amounts obtained by subtracting the amount set forth in item (ii) from the amount set forth in item (i) pertaining to each of the Insurers of employee insurance, etc. is equal to the sum of the amounts obtained by subtracting the amount set forth in item (iv) from the amount set forth in item (iii):
(i) the amount obtained by multiplying the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old by the estimated participant adjustment rate;
(ii) the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old;
(iii) the amount obtained by multiplying the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old, when an Insurer of employee insurance, etc. is deemed to be an Insurer other than an Insurer of employee insurance, etc., by the estimated participant adjustment rate;
(iv) the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old Act when Insurers of employee insurance, etc. are deemed to be insurers other than Insurers of employee insurance, etc.
(6) The estimated premium adjustment rate referred to in paragraph (4) is the rate calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare so that the total of the amounts set forth in item (i) pertaining to each of the Insurers of employee insurance, etc. is equal to the total of the amounts set forth in item (ii):
(i) the amount arrived at when the estimated amount of the covered benefit expenses referred to in the items of paragraph (1) is multiplied by the estimated remuneration adjustment rate and the estimated participant adjustment rate;
(ii) the amount arrived at when the estimated amount of the covered benefit expenses referred to in the items of paragraph (1) is multiplied by the estimated participant adjustment rate.
(7) The estimated participant adjustment rate referred to in paragraph (3), paragraph (4), paragraph (5), items (i) and (iii), and the items of the preceding paragraph is the rate calculated for each insurer based on the rate arrived at when the prospective total number of subscribers who are young-old adults accounts for the prospective total number of subscribers for all insurers in the relevant fiscal year is divided by the prospective total number of subscribers who are young-old adults accounts for the prospective total number of subscribers for the relevant insurers in the same fiscal year (or, if that rate is less than the minimum rate in the same fiscal year (meaning the rate specified by Cabinet Order in consideration of trends in the rate of the prospective total number of subscribers who are young-old adults accounts for the prospective total number of subscribers for all insurers in the same fiscal year; hereinafter the same applies in this paragraph and paragraph (7) of the following Article), the minimum rate), pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare.
(8) The total standardized amount of remuneration referred to in paragraph (4), item (i) is the amount obtained by correcting, pursuant to the provisions of Cabinet Order, the total sum of the amounts specified in the following items for each fiscal year in accordance with the category of insurer set forth in each of those items:
(i) a Japan Health Insurance Association or health insurance society: the standard remuneration (meaning the standard monthly remuneration amount and the Bonus Amount) prescribed in the Health Insurance Act or the Mariners Insurance Act for each insured;
(ii) the monthly amount of standard compensation and the amount of standard end-of-term allowance, etc. prescribed in the National Public Officers mutual aid association Act or the mutual aid association Act on local public employee, etc. for each mutual aid association Partner;
(iii) the standard monthly remuneration amount and the Bonus Amount prescribed in the Private School Teachers Mutual Aid Act for each member of the Promotion and Mutual Aid Corporation for Private Schools of Japan;
(iv) national health insurance societies (limited to those who are insurers of employee insurance, etc.): the amount specified by Prefectural Order of the Ministry of Health, Labour and Welfare as equivalent to the amounts specified in the preceding three items for each member.
(9) The per capita average estimated amount of young-old benefit expenses referred to in paragraph (2), item (ii), (b) is the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the average of the estimated amount of young-old benefit expenses per Participant who is a young-old pertaining to all Insurers.
(Fixed Young-Old Subsidies)
Article 35  (1) The amount of the fixed Young-Old Subsidy referred to in Article 33, paragraph (1) is the amount specified in the following items in accordance with the category of Insurer set forth in each of those items.
(i) insurers of employee insurance, etc.: the sum of the amounts listed in (a) and (b):
(a) the amount equivalent to two-thirds of the amount obtained by subtracting the amount set forth in 4. from the sum of the amounts set forth in 1. through 3. (if the amount is less than zero, it is deemed to be zero):
1. the amount of benefit expenses subject to adjustment pertaining to the insurer in the fiscal year before the previous fiscal year;
2. the amount obtained by first dividing the amount of the final Medical Care Assistance for the Elderly Aged 75 and over of the Article 119, paragraph (1) pertaining to the insurer in the fiscal year before the previous fiscal year by the final Medical Care Assistance for the Elderly Aged 75 and over adjustment rate set forth in the items of Article 121, paragraph (1) pertaining to the insurer in the same fiscal year, and then multiplying the result by the rate calculated for each of the insurers based on the ratio of the number of subscribers who are young-old to the number of subscribers pertaining to the insurer in the same fiscal year (hereinafter referred to as the "final amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to young-old");
3. the amount calculated pursuant to the provisions of Act on the Prevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases as the amount pertaining to subscribers who are young-old persons out of the amount of contributions to ensure medical care in the early stage of an epidemic (hereinafter referred to as "contributions to ensure medical care in the early stage of an epidemic") pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare (Act No. 114 of 1998) pertaining to the insurers in the fiscal year before the previous fiscal year (hereinafter referred to as "amount of contributions to ensure medical care in the early stage of an epidemic pertaining to young-old persons");
4. the final base amount subject to adjustment in the fiscal year before the previous fiscal year;
(b) the amount equivalent to one third of the amount obtained by subtracting the base amount subject to adjustment after the adjustment of fixed remunerations in the fiscal year before the previous fiscal year from the sum of the amount of benefit expenses subject to adjustment pertaining to the insurer, the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old, and the amount of contributions for securing medical care in the early stage of an epidemic pertaining to the young-old in the same fiscal year (if the amount is less than zero, it is deemed to be zero);
(ii) insurers other than insurers of employee insurance, etc.: the amount obtained by subtracting the final base amount for adjustment in the fiscal year before the relevant fiscal year from the sum of the amount of benefit expenses subject to adjustment pertaining to the relevant insurers, the final amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old, and the amount of contributions for securing medical care in the early stage of an epidemic pertaining to the young-old in the same fiscal year (if the amount is less than zero, it is deemed to be zero).
(2) The amount of benefit expenses subject to adjustment referred to in the items of the preceding paragraph is the amount obtained by multiplying the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the average of the per capita average amount of benefit expenses subject to adjustment (meaning the amount obtained by dividing the amount obtained by deducting the amount set forth in item (ii) from the amount set forth in item (i) in each fiscal year by the number of subscribers who are young-old adults pertaining to the relevant insurer in each fiscal year calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare) pertaining to the relevant insurer in each fiscal year two years before the previous fiscal year, the fiscal year which includes April 1 of the year preceding the year which includes the first day of the fiscal year two years before the previous fiscal year, and the fiscal year which includes April 1 of the year two years before the year which includes the first day of the fiscal year two years before the previous fiscal year by the number of subscribers who are young-old adults pertaining to the relevant insurer in each fiscal year calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare:
(i) the amount calculated pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare as the amount of expenses required for benefits by the insurer which pertain to subscribers who are young-old (hereinafter referred to as the "amount of young-old benefit expenses");
(ii) the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the portion of the amount of young-old benefit expenses pertaining to the insurers if the insurers are the insurers in excess of the fixed standards (meaning the insurers for which the rate obtained by dividing the amount listed in (a) by the amount listed in (b) exceeds the rate specified by Cabinet Order set forth in paragraph (2), item (ii) of the preceding Article), which exceeds the amount obtained by multiplying the amount listed in (b) by the rate specified by the Cabinet Order:
(a) the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the amount of young-old benefit expenses per member who is a young-old pertaining to a single insurer;
(b) the average per person young-old benefit cost.
(3) The final base amount for adjustment set forth in the items of paragraph (1) is the amount obtained by multiplying the total of the amount of benefit expenses subject to adjustment set forth in the items of the same paragraph pertaining to the insurer, the final amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old (in the case of Insurers of employee insurance, etc., the amount obtained by multiplying the amount by the final amount adjustment rate), and the amount of contributions to ensure medical care in the early stage of an epidemic pertaining to the young-old, by the final participant adjustment rate.
(4) The base amount subject to adjustment after adjustment of fixed compensation referred to in paragraph (1), item (i), (b) is the amount obtained by multiplying the sum of the sum of the amount of payment expenses subject to adjustment set forth in the items of the same paragraph pertaining to the insurer and the amount of contributions to ensure medical care in the early stage of an epidemic pertaining to the young-old by the rate obtained by dividing the amount set forth in item (i) in the fiscal year before the previous fiscal year by the amount set forth in item (ii) (referred to as the "fixed compensation adjustment rate" in paragraph (6), item (i)) and the fixed compensation adjustment rate for payment expenses, etc., and the amount obtained by multiplying the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old by the fixed amount adjustment rate, by the fixed participant adjustment rate:
(i) the amount arrived at when the insurer's total standardized amount of compensation (meaning the total standardized amount of compensation as prescribed in paragraph (8) of the preceding Article; the same applies in the following item and in Article 121, paragraph (1), item (i), (a) and (b)) is divided by the number of participants associated with that insurer, as calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare;
(ii) the amount calculated pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare as the amount obtained by dividing the sum of the total amount of standardized remunerations pertaining to all Insurers of employee insurance, etc. by the total number of subscribers pertaining to all Insurers of employee insurance, etc.
(5) The fixed amount adjustment rate referred to in the preceding two paragraphs is the rate calculated pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare so that the sum of the amounts obtained by subtracting the amount set forth in item (ii) from the amount set forth in item (i) pertaining to each of the insurers of employee insurance, etc. is equal to the sum of the amounts obtained by subtracting the amount set forth in item (iv) from the amount set forth in item (iii):
(i) the amount arrived at when the final amount of the Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old is multiplied by the final participant adjustment rate;
(ii) the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old;
(iii) the amount obtained by multiplying the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old by the Fixed Participant Adjustment Rate when an Insurer of employee insurance, etc. is deemed to be an Insurer other than an Insurer of employee insurance, etc.;
(iv) the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the Young-Old when an Insurer of employee insurance, etc. is deemed to be an Insurer other than an Insurer of employee insurance, etc.
(6) The adjustment rate for fixed benefit expenses, etc. set forth in paragraph (4) is the rate calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare so that the total of the amounts listed in item (i) pertaining to each of the Insurers of employee insurance, etc. is equal to the total of the amounts listed in item (ii):
(i) the amount obtained by multiplying the sum of the amount of payment expenses subject to adjustment and the amount of contributions for ensuring medical care in the early stage of an epidemic pertaining to young-old persons set forth in the items of paragraph (1) by the fixed remuneration adjustment rate and the fixed participant adjustment rate;
(ii) the amount obtained by multiplying the sum of the amount of payment expenses subject to adjustment set forth in the items of paragraph (1) and the amount of contributions to ensure medical care in the early stage of an epidemic pertaining to the young-old by the fixed participant adjustment rate.
(7) The fixed participant adjustment rate referred to in paragraph (3), paragraph (4), paragraph (5), items (i) and (iii), and the items of the preceding paragraph is the rate calculated for each of the insurers pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare, based on the rate arrived at when the percentage of the total number of participants who are young-old to the total number of participants for all insurers in the fiscal year before the previous fiscal year is divided by the percentage of the number of participants who are young-old to the number of participants for the relevant insurers in the same fiscal year (if that percentage is less than the minimum percentage in the same fiscal year, the minimum percentage).
(8) The per capita average amount of young-old benefit expenses referred to in paragraph (2), item (ii), (b) is the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare as the average amount of young-old benefit expenses per one member who is a young-old pertaining to all insurers.
(Collection and Payment Obligation of Young-Old Payments)
Article 36  (1) The Payment Fund collects Young-Old Payments and contributions for administrative expenses related to the Young-Old (hereinafter referred to as "Young-Old Payments, etc.") from Insurers each fiscal year in order to cover the expenses required for the services listed in Article 139, paragraph (1), item (i) and the handling of affairs relating to the services.
(2) An insurer is liable to pay young-old payments.
(Amount of Young-Old Payments)
Article 37  (1) The amount of Young-Old Payments collected from each Insurer pursuant to the provisions of paragraph (1) of the preceding Article is the estimated amount of Young-Old Payments for the relevant fiscal year; provided, however, that when the estimated amount of Young-Old Payments for the fiscal year before the previous fiscal year exceeds the fixed amount of Young-Old Payments for the same fiscal year, the amount is to be the amount obtained by subtracting the sum of the excess amount and the Young-Old Payment Adjustment Amount pertaining to the excess amount from the estimated amount of Young-Old Payments for the relevant fiscal year, and when the estimated amount of Young-Old Payments for the fiscal year before the previous fiscal year is less than the fixed amount of Young-Old Payments for the same fiscal year, the amount is to be the amount obtained by adding the estimated amount of Young-Old Payments for the relevant fiscal year to the sum of the amount of the shortfall and the Young-Old Payment Adjustment Amount pertaining to the.
(2) The Young-Old Payment Adjustment Amount prescribed in the preceding paragraph is the amount calculated for each of the Insurers pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare by taking into consideration the interest arising from the excess or deficiency between the estimated Young-Old Payments and the fixed Young-Old Payments pertaining to all of the Insurers in the fiscal year before the previous fiscal year and other circumstances.
(Estimated Young-Old Payments)
Article 38  (1) The estimated amount of Young-Old Payments referred to in paragraph (1) of the preceding Article is the amount specified in each of the following items in accordance with the category of Insurer set forth in the relevant item:
(i) an insurer in excess of the estimated amount of young-old payments before burden adjustment (meaning an insurer whose estimated amount equivalent to young-old payments before burden adjustment in the fiscal year exceeds zero and whose total amount set forth in (a) exceeds the amount set forth in (b) (excluding an insurer in excess of the special estimated amount of burden adjustment); hereinafter the same applies in this Article): the sum of the estimated amount of burden adjustment and the amount obtained by subtracting the estimated amount subject to burden adjustment (meaning the amount obtained by subtracting the amount set forth in (b) from the total amount set forth in (a) (when the amount exceeds the estimated amount equivalent to young-old payments before burden adjustment, the estimated amount equivalent to young-old payments before burden adjustment); the same applies in paragraph (3)) from the estimated amount equivalent to young-old payments before burden adjustment:
(a) the sum total of the following amounts:
1. the amount equivalent to estimated young-old payments before burden adjustment in the relevant fiscal year;
2. the amount obtained by dividing the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over of the Article 119, paragraph (1) pertaining to the insurer in the relevant fiscal year by the estimated Medical Care Assistance for the Elderly Aged 75 and over adjustment rate set forth in the items of Article 120, paragraph (1) pertaining to the insurer in the same fiscal year;
(b) the amount arrived at when the sum total of the following amounts is multiplied by the base rate for burden adjustment for the relevant fiscal year:
1. the total amount set forth in (a);
2. the amount calculated as specified by Order of Article 173, paragraph (2) as the prospective amount of expenses required for benefits by the insurer in the relevant fiscal year (including expenses required for payment of day laborer contributions prescribed in Order of the Ministry of Health, Labour and Welfare of the Health Insurance Act; referred to as "expenses required for benefits by insurers, etc." in (b), 2. of the following item, paragraph (1), item (i), (b), 2. and item (ii), (b), 2. of the following Article);
(ii) an Insurer whose Estimated Amount Equivalent to Young-Old Payments Prior to Burden Adjustment in the fiscal year exceeds the standard for special estimated burden adjustment (meaning an Insurer whose Estimated Amount Equivalent to Young-Old Payments Prior to Burden Adjustment in the fiscal year exceeds zero, whose total amount set forth in (a) exceeds the amount set forth in (b), and whose estimated financial strength for the same fiscal year as calculated pursuant to the provisions of Cabinet Order is less than the standard specified by Cabinet Order; hereinafter the same applies in this Article): the sum of the amount obtained by subtracting the estimated amount subject to special burden adjustment (meaning the amount obtained by subtracting the amount set forth in (b) from the total amount set forth in (a) (when the amount exceeds the estimated amount equivalent to Young-Old Payments Prior to Burden Adjustment, the estimated amount equivalent to Young-Old Payments Prior to Burden Adjustment); the same applies in paragraph (3)) from the estimated amount equivalent to Young;
(a) the sum total of the following amounts:
1. the amount equivalent to estimated young-old payments before burden adjustment in the relevant fiscal year;
2. the amount obtained by dividing the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over of the Article 119, paragraph (1) pertaining to the insurer in the relevant fiscal year by the estimated Medical Care Assistance for the Elderly Aged 75 and over adjustment rate set forth in the items of Article 120, paragraph (1) pertaining to the insurer in the same fiscal year;
(b) the amount arrived at when the sum total of the following amounts is multiplied by the base rate for special burden adjustment for the relevant fiscal year;
1. the total amount set forth in (a);
2. the amount calculated as specified by Order of Order of the Ministry of Health, Labour and Welfare as the prospective amount of expenses, etc. necessary for benefits to be paid by the insurer in the relevant fiscal year;
(iii) an insurer other than an insurer in excess of the standard for estimated burden adjustment and an insurer in excess of the special standard for estimated burden adjustment: the sum of the amount equivalent to estimated young-old payments before burden adjustment and the estimated amount of burden adjustment.
(2) The estimated amount equivalent to Young-Old Payments before burden adjustment referred to in the items of the preceding paragraph is the amount specified in the following items according to the categories of Insurers set forth in the respective items.
(i) insurers of employee insurance, etc.: the sum of the amounts listed in (a) and (b):
(a) the amount equivalent to two-thirds of the amount obtained by subtracting the sum of the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over expense subject to adjustment set forth in the items of Article 34, paragraph (1) pertaining to the insurer and the estimated amount of benefits pertaining to the young-old (if the amount is less than zero, it is deemed to be zero) from the estimated base amount of benefits subject to adjustment set forth in the items of the same paragraph;
(b) the amount equivalent to one third of the amount obtained by deducting the sum of the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over expense subject to adjustment set forth in the items of Article 34, paragraph (1) pertaining to the insurer and the estimated amount of benefits pertaining to the young-old (if the amount is less than zero, it is deemed to be zero) from the base amount of subject to adjustment after adjustment of estimated remunerations set forth in Article 34, paragraph (1), item (i), (b);
(ii) insurers other than insurers covered by employee insurance, etc.: the amount obtained by deducting the sum of the estimated amount of benefit expenses subject to adjustment set forth in the items of Article 34, paragraph (1) pertaining to the relevant insurers and the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old (if the relevant amount is less than zero, it is deemed to be zero) from the estimated base amount subject to adjustment set forth in the items of the same paragraph.
(3) The estimated amount of burden adjustment referred to in the items of paragraph (1) is the amount obtained by multiplying the amount obtained by first dividing the sum of the amounts set forth in the following items for the relevant fiscal year by the estimated total number of subscribers for all insurers in the relevant fiscal year calculated as specified by Order of the Order of the Ministry of Health, Labour and Welfare, then multiplying the product by the estimated number of subscribers for the relevant insurers in the relevant fiscal year calculated as specified by Order of the Order of the Ministry of Health, Labour and Welfare, then multiplying the product by the estimated adjustment rate for the burden adjustment:
(i) the total estimated amount subject to burden adjustment pertaining to all insurers in excess of the standard for estimated burden adjustment;
(ii) the total of the prospective amounts subject to burden adjustment pertaining to all insurers in excess of the special estimated burden adjustment standards;
(iii) one third of the total amount calculated by deducting the prospective amount subject to burden adjustment from the prospective amount subject to special burden adjustment pertaining to all insurers exceeding the special estimated burden adjustment standards (referred to as the "total amount, etc. of the prospective amount of special burden adjustment" in Article 93, paragraph (3)).
(4) The base rate for burden adjustment referred to in paragraph (1), item (i), (b) is the rate specified by Cabinet Order for each fiscal year so that the ratio of insurers in excess of the estimated burden adjustment standard to all insurers is the ratio specified by Cabinet Order as being extremely small.
(5) The standard rate for special burden adjustment referred to in paragraph (1), item (ii), (b) is a rate specified by Cabinet Order for each fiscal year so that the percentage of insurers exceeding the special estimated burden adjustment standard among all insurers is the percentage specified by Cabinet Order as being small.
(6) The estimated burden adjustment adjustment rate referred to in paragraph (3) is calculated pursuant to the provisions of Cabinet Order within the range of 90 percent to 110 percent, taking into consideration the estimated amount of young-old benefit expenses per participant who is a young-old.
(Fixed Young-Old Payments)
Article 39  (1) The amount of the final and binding young-old payments referred to in Article 37, paragraph (1) is the amount specified in the following items in accordance with the category of the insurer set forth in each of those items:
(i) an Insurer in Excess of the Determined Threshold for Burden Adjustment (meaning an Insurer whose Amount Equivalent to Determined Young-Old Payments Prior to Burden Adjustment exceeds zero in the fiscal year before the previous fiscal year, and whose total amount set forth in (a) exceeds the amount set forth in (b) (excluding an Insurer in Excess of the Special Determined Threshold for Burden Adjustment set forth in the following item); hereinafter the same applies in this Article): the sum of the amount obtained by subtracting the amount subject to burden adjustment (meaning the amount obtained by subtracting the amount set forth in (b) from the total amount set forth in (a) (when the amount exceeds the Amount Equivalent to Determined Young-Old Payments Prior to Burden Adjustment, the amount equivalent to Determined Young-Old Payments Prior to Burden Adjustment); the same applies in paragraph (3)) from the:
(a) the sum total of the following amounts:
1. the amount equivalent to the confirmed young-old payments before burden adjustment in the fiscal year before the previous fiscal year;
2. the amount obtained by dividing the amount of final Medical Care Assistance for the Elderly Aged 75 and over of Article 119, paragraph (1) pertaining to the insurer in the fiscal year before the previous fiscal year by the final Medical Care Assistance for the Elderly Aged 75 and over adjustment rate set forth in the items of Article 121, paragraph (1) pertaining to the insurer in the same fiscal year;
(b) the amount arrived at when the sum total of the following amounts is multiplied by the base rate for burden adjustment referred to in paragraph (1), item (i), (b) of the preceding Article for the fiscal year before the previous fiscal year;
1. the total amount set forth in (a);
2. the amount of expenses, etc. required for benefits by the insurer and the amount of contributions to ensure medical care in the early stage of an epidemic in the fiscal year before the previous fiscal year;
(ii) an Insurer whose Amount Equivalent to Confirmed Young-Old Payments Prior to Burden Adjustment is greater than zero in the fiscal year before the previous fiscal year, whose total amount set forth in (a) exceeds the amount set forth in (b), and whose financial capacity for the same fiscal year, as calculated pursuant to the provisions of Cabinet Order, is less than the standard specified by Cabinet Order (hereinafter the same applies in this Article): the sum of the amount obtained by subtracting the Amount Subject to Special Burden Adjustment (meaning the amount obtained by subtracting the amount set forth in (b) from the total amount set forth in (a) (when the amount exceeds the Amount Equivalent to Confirmed Young-Old Payments Prior to Burden Adjustment, it is to be the Amount Equivalent to Confirmed Young-Old Payments Prior to Burden Adjustment); the same applies in paragraph (3)) from the Amount Equivalent to Confirmed Young-Old Payments Prior to;
(a) the sum total of the following amounts:
1. the amount equivalent to the confirmed young-old payments before burden adjustment in the fiscal year before the previous fiscal year;
2. the amount obtained by dividing the amount of final Medical Care Assistance for the Elderly Aged 75 and over of Article 119, paragraph (1) pertaining to the insurer in the fiscal year before the previous fiscal year by the final Medical Care Assistance for the Elderly Aged 75 and over adjustment rate set forth in the items of Article 121, paragraph (1) pertaining to the insurer in the same fiscal year;
(b) the amount arrived at when the sum total of the following amounts is multiplied by the base rate for special burden adjustment referred to in paragraph (1), item (ii), (b) of the preceding Article for the fiscal year before the previous fiscal year:
1. the total amount set forth in (a);
2. the amount of expenses, etc. required for benefits by the insurer and the amount of contributions to ensure medical care in the early stage of an epidemic in the fiscal year before the previous fiscal year;
(iii) an insurer other than an insurer in excess of the fixed burden adjustment standard and a special insurer in excess of the fixed burden adjustment standard: the sum of the amount equivalent to the determined young-old payments before burden adjustment and the burden adjustment amount.
(2) The amount equivalent to the confirmed young-old payments before burden adjustment referred to in the items of the preceding paragraph is the amount specified in the following items in accordance with the category of insurer set forth in each of those items.
(i) insurers of employee insurance, etc.: the sum of the amounts listed in (a) and (b):
(a) the amount equivalent to two-thirds of the amount obtained by subtracting the sum of the amount of benefits expenses subject to adjustment set forth in the items of Article 35, paragraph (1) pertaining to the insurer, the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old, and the amount of contributions to ensure medical care in the early stage of an epidemic pertaining to the young-old (if the amount is less than zero, it is deemed to be zero) from the fixed base amount subject to adjustment set forth in the items of the same paragraph;
(b) the amount equivalent to one third of the amount obtained by deducting, from the base amount for adjustment after adjustment of fixed compensation set forth in Article 35, paragraph (1), item (i), (b), the sum of the amount of benefit expenses subject to adjustment set forth in the items of the same paragraph pertaining to the insurer, the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old, and the amount of contributions to ensure medical care in the early stage of an epidemic pertaining to the young-old (if the amount is less than zero, it is deemed to be zero);
(ii) insurers other than insurers of employee insurance, etc.: the amount obtained by subtracting the sum of the amount of benefit expenses subject to adjustment set forth in the items of Article 35, paragraph (1) pertaining to the relevant insurers, the fixed amount of Medical Care Assistance for the Elderly Aged 75 and over pertaining to the young-old, and the amount of contributions to ensure medical care in the early stage of an epidemic pertaining to the young-old from the fixed base amount subject to adjustment set forth in the items of the same paragraph (if the amount is less than zero, it is deemed to be zero).
(3) The burden adjustment amount set forth in the items of paragraph (1) is the amount obtained by multiplying the amount obtained by first dividing the sum of the amounts set forth in the following items for the fiscal year before the previous fiscal year by the total number of subscribers for all insurers in the same fiscal year calculated as specified by Order of Order of the Ministry of Health, Labour and Welfare, and then multiplying the product by the number of subscribers for the relevant insurers in the same fiscal year calculated as specified by Order of Order of the Ministry of Health, Labour and Welfare, and then multiplying the product by the fixed burden adjustment adjustment rate:
(i) the total amount subject to burden adjustment pertaining to all insurers in excess of the fixed burden adjustment standards;
(ii) the total amount subject to burden adjustment pertaining to all insurers in excess of the special standards for burden adjustment;
(iii) one third of the total amount (referred to as the "total amount of special burden adjustment, etc." in Article 93, paragraph (3)) arrived at when the amount subject to burden adjustment is deducted from the amount subject to special burden adjustment pertaining to all insurers in excess of the special established standard for burden adjustment.
(4) The adjustment rate for the amount of settled burden adjustment referred to in the preceding paragraph is calculated pursuant to the provisions of Cabinet Order within the range of 90 percent to 110 percent, taking into consideration the amount of young-old benefit expenses per participant who is a young-old.
(Amount of Contributions for Office Expenses Related to the Young-Old)
Article 40  The amount of contributions for the administrative expenses related to the Young-Old collected from each of the Insurers pursuant to the provisions of Article 36, paragraph (1) is the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, based on the estimated amount of expenses required for the processing of affairs concerning the services of the Payment Fund set forth in Article 139, paragraph (1), item (i) in the relevant fiscal year, in accordance with the estimated number of subscribers pertaining to each of the Insurers, as specified by Order of the Ministry of Health, Labour and Welfare.
(Special Provisions for the Amount of the Young-Old Subsidy in the Case of a Merger of Insurers)
Article 41  Cabinet Order provides for special provisions for the calculation of the amount of Young-Old Subsidies and Young-Old Payments pertaining to an Insurer incorporated as a result of a merger or split, an Insurer surviving a merger or split, or an Insurer succeeding to the rights and obligations of a dissolved Insurer.
(Determination and Notification of the Amount of the Young-Old Subsidy)
Article 42  (1) The Payment Fund must determine the amount of the Young-Old Subsidy to be granted to each Insurer for each fiscal year and notify each Insurer of the amount of the Young-Old Subsidy to be granted to the person, the method of grant, and other necessary matters.
(2) If it becomes necessary to change the amount of the Young-Old Subsidy after the amount of the Young-Old Subsidy has been determined pursuant to the provisions of the preceding paragraph, the Payment Fund must change the amount of the Young-Old Subsidy to be granted to each of the relevant Insurers and notify each of the relevant Insurers of the changed amount of the Young-Old Subsidy.
(3) The Payment Fund, in the case where the amount of the Young-Old Subsidy granted to an insurer is less than the amount of the Young-Old Subsidy after the change pursuant to the provisions of the preceding paragraph, must notify the insurer of the method of grant and other necessary matters, along with the notice pursuant to the provisions of the same paragraph, with regard to the shortfall; and in the case where the amount of the Young-Old Subsidy exceeds the amount of the Young-Old Subsidy after the change pursuant to the provisions of the same paragraph, the Payment Fund must appropriate the excess amount to the unpaid Young-Old Subsidy, if any, and have the insurer return the balance, if any, or have the insurer return the unpaid subsidy, if none.
(Determination and Notification of the Amount of Young-Old Payments)
Article 43  (1) The Payment Fund must determine the amount of Young-Old Payments, etc. to be paid by each Insurer for each fiscal year, and notify each Insurer of the amount of Young-Old Payments, etc. to be paid by the Insurer, the method of payment, the due date of payment, and other necessary matters.
(2) If it becomes necessary to change the amount of Young-Old Payments, etc., after the amount of Young-Old Payments, etc., has been determined pursuant to the provisions of the preceding paragraph, the Payment Fund must change the amount of Young-Old Payments, etc., to be paid by each relevant Insurer and notify each relevant Insurer of the changed amount of Young-Old Payments, etc.
(3) If the amount of Young-Old Payments, etc. paid by an Insurer is less than the amount of Young-Old Payments, etc. after the change pursuant to the provisions of the preceding paragraph, the Payment Fund must give notice pursuant to the provisions of the same paragraph and also give notice of the method of payment, due date for payment, and other necessary matters with regard to the shortfall; and if the amount of Young-Old Payments, etc. exceeds the amount of Young-Old Payments, etc. after the change pursuant to the provisions of the same paragraph, the Payment Fund must appropriate the excess amount to any unpaid Young-Old Payments, etc. or any other money to be collected from the Payment Fund pursuant to the provisions of this Chapter, and return the balance if any, or return the excess amount if there is no unpaid money to be collected.
(Demand and disposition to collect arrears)
Article 44  (1) If an Insurer fails to make a Young-Old Payment, etc. by the due date for payment, the Payment Fund must demand payment by the due date.
(2) The Payment Fund, when it makes a demand pursuant to the provisions of the preceding paragraph, must issue a written demand to the insurer. In this case, the due date to be designated in the written demand must be a day on which ten days or more have elapsed from the day on which the written demand is issued.
(3) The Payment Fund, when an Insurer who has received a written demand pursuant to the provisions of paragraph (1) fails to pay the Young-Old Payments pertaining to the written demand and the delinquent charge pursuant to the provisions of the following Article in full by the designated due date, is to request the Minister of Health, Labour and Welfare or the prefectural governor to collect the payment pursuant to the provisions of a Cabinet Order.
(4) When a request for collection under the provisions of the preceding paragraph is received, the Minister of Health, Labour and Welfare or the prefectural governor may make a disposition in accordance with the rules for a national tax disposition to collect arrears.
(Delinquent Charges)
Article 45  (1) When a demand for payment of Young-Old Payments, etc. is made pursuant to the provisions of paragraph (1) of the preceding Article, the Payment Fund collects a delinquent charge calculated based on the number of days from the day after the due date for payment until the day before the day of full payment or attachment of property, at a rate of 14.5% per annum on the amount of Young-Old Payments, etc. pertaining to the demand; provided, however, that this does not apply when the amount of Young-Old Payments, etc. pertaining to the demand is less than one thousand yen.
(2) In the case referred to in the preceding paragraph, if a part of the amount of the Young-Old Payments, etc. is paid, the amount of the Young-Old Payments, etc. to be used as the basis for calculating the amount of delinquent charge pertaining to the period after the date of the payment is the amount obtained by deducting the amount of the Young-Old Payments, etc. that was paid.
(3) In the calculation of delinquent charges, if the amount of the young-old payments, etc. set forth in the preceding two paragraphs includes a fraction of less than one thousand yen, the fraction is rounded down.
(4) If the amount of delinquency calculated pursuant to the provisions of the preceding three paragraphs includes a fraction of less than one hundred yen, the fraction is rounded down.
(5) A delinquency charge is not collected if the case falls under any of the following items; provided, however, that in the case referred to in item (iii), the delinquency charge is limited to the amount corresponding to the period during which the execution of the delinquency charge was suspended or stayed:
(i) if the young-old payments, etc. are paid in full by the due date designated in the written demand;
(ii) if the amount of arrears is less than 100 yen;
(iii) when the execution of disposition to collect arrears for Young-Old Payments, etc. is suspended or suspended;
(iv) if it is found that there is a compelling reason for not paying Young-Old Payments.
(Payment Grace Period)
Article 46  (1) The Payment Fund, when it is found to be extremely difficult for Insurers to pay Young-Old Payments, etc. due to unavoidable circumstances, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare, based on an application by the relevant Insurers and with the approval of the Minister of Health, Labour and Welfare, may grant a grace period for a part of the payment for a period not exceeding one year from the due date for the payment.
(2) The Payment Fund, when having granted a grace period pursuant to the provisions of the preceding paragraph, must notify the Insurer of such fact, the amount of the Young-Old Payments, etc. pertaining to the grace period, the grace period, and other necessary matters.
(3) If the Payment Fund has granted a grace period pursuant to the provisions of paragraph (1), the Payment Fund may not make a demand pursuant to the provisions of Article 44, paragraph (1) or request collection pursuant to the provisions of paragraph (3) of the same Article with respect to the Young-Old Payments, etc. pertaining to the grace period during the grace period.
Chapter IV Late-Stage Elderly Medical Care System
Section 1 General Provisions
(Old-Old Healthcare)
Article 47  Medical care for the elderly is to provide necessary benefits in relation to the illness, injury, or death of an elderly person.
(Establishment of a Cross-Regional Federation)
Article 48  A Municipality, in order to administer affairs concerning Old-Old Healthcare (excluding affairs concerning the collection of insurance premiums and affairs specified by a Cabinet Order as contributing to the promotion of the benefits of the insured), is to establish, for each area of a prefecture, a cross-regional federation to which all Municipalities within the relevant area belong (hereinafter referred to as a "Association of Medical Care Systems for the Elderly Aged 75 and older").
(Special Accounts)
Article 49  A Association of Medical Care Systems for the Elderly Aged 75 and older and a municipality, pursuant to the provisions of a Cabinet Order, must establish a special account for revenue and expenses related to medical care for the elderly.
Section 2 Insured
(insured)
Article 50  A person who falls under any of the following items is to be a insured for medical care for the elderly provided by the Association of Medical Care Systems for the Elderly Aged 75 and older:
(i) a person who is 75 years of age or older and has a domicile within the area of the Association of Medical Care Systems for the Elderly Aged 75 and older;
(ii) a person who is domiciled within the district of a Association of Medical Care Systems for the Elderly Aged 75 and older and is 65 years of age or older but under 75 years of age, who has been certified by the Association of Medical Care Systems for the Elderly Aged 75 and older, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, as being disabled to the extent specified by Cabinet Order.
(Exclusion from Application)
Article 51  Notwithstanding the provisions of the preceding Article, a person who falls under any of the following items is not eligible to be a insured for medical care for the elderly provided by the Association of Medical Care Systems for the Elderly Aged 75 and older:
(i) a person who belongs to a household receiving public assistance under the Public Assistance Act (Act No. 144 of 1950) (excluding a household for which public assistance has been suspended);
(ii) beyond what is set forth in the preceding item, a person who has a special reason to be excluded from the application of Old-Old Healthcare and who is specified by Order of Order of the Ministry of Health, Labour and Welfare.
(Time of Acquisition of Qualification)
Article 52  A insured for medical care for the elderly provided by a Association of Medical Care Systems for the Elderly Aged 75 and older acquires eligibility from the day on which the person comes to fall under any of the following items or the day on which the person no longer falls under any of the items of the preceding Article:
(i) when a person who is domiciled within the area of the relevant Association of Medical Care Systems for the Elderly Aged 75 and older (excluding a person who has received the certification set forth in Article 50, item (ii)) has reached 75 years of age;
(ii) when a person who is 75 years of age or older has come to have a domicile within the area of the relevant Association of Medical Care Systems for the Elderly Aged 75 and older;
(iii) when a person who is 65 years of age or older and under 75 years of age and who has a domicile within the area of the relevant Association of Medical Care Systems for the Elderly Aged 75 and older has received the certification set forth in Article 50, item (ii).
(Time of Forfeiture of Status)
Article 53  (1) A insured for medical care for the elderly provided by a Association of Medical Care Systems for the Elderly Aged 75 and older loses eligibility from the day following the day on which the person no longer has domicile in the area of the relevant Association of Medical Care Systems for the Elderly Aged 75 and older, no longer falls under the condition set forth in Article 50, item (ii), or comes to fall under the person set forth in Article 51, item (ii); provided, however, that if the person comes to have domicile in the area of another Association of Medical Care Systems for the Elderly Aged 75 and older on the day on which the person no longer has domicile in the area of the relevant Association of Medical Care Systems for the Elderly Aged 75 and older, the person loses eligibility from that day.
(2) A insured for medical care for the elderly provided by a Association of Medical Care Systems for the Elderly Aged 75 and older loses eligibility as such from the day on which the person comes to fall under the category of a person provided for in Article 51, item (i).
(Notification)
Article 54  (1) A insured, pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare, must notify the Association of Medical Care Systems for the Elderly Aged 75 and older of particulars concerning the acquisition and forfeiture of status as a insured and other necessary particulars.
(2) The householder of a household to which a insured belongs may make a notification under the provisions of the preceding paragraph pertaining to the insured on behalf of the insured belonging to the household.
(3) When a insured is in a situation where it is unable to receive the electronic certification confirmation prescribed in Article 64, paragraph (3), the insured may request the Association of Medical Care Systems for the Elderly Aged 75 and older to deliver a document stating the matters specified by Order of the Order of the Ministry of Health, Labour and Welfare as the information pertaining to the status of the insured in the relevant situation or to provide the matters by electronic or magnetic means (meaning a method using an electronic data processing system or any other method using information and communications technology, which is specified by Order of the Order of the Ministry of Health, Labour and Welfare; hereinafter the same applies in this paragraph through paragraph (5)), pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare. In this case, the Association of Medical Care Systems for the Elderly Aged 75 and older is to promptly deliver the document to the insured that has requested the delivery of the document and provide the matters by electronic or magnetic means to the insured that has requested the provision by electronic or magnetic means, pursuant to the provisions of Order of the Ministry of Justice. Order of the Ministry of Health, Labour and Welfare.
(4) A Order of the Ministry of Health, Labour and Welfare that has been issued a document as referred to in the preceding paragraph pursuant to the provisions of that paragraph or that has been provided with the information that Order of the insured prescribes which is referred to in that paragraph by electronic or magnetic means may obtain the confirmation referred to in the main clause of Article 64, paragraph (3) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 82, paragraph (6)) or Article 78, paragraph (3) (including as applied mutatis mutandis pursuant to Article 82, paragraph (6)) by presenting that document or something that indicates the information in a way that Order of the Order of the Ministry of Health, Labour and Welfare prescribes.
(5) In order to confirm the facts pertaining to the status of the insured, the insured may request the Association of Medical Care Systems for the Elderly Aged 75 and older to deliver a document stating the relevant facts or to provide the matters to be stated in the relevant document by electronic or magnetic means, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare. In this case, the Association of Medical Care Systems for the Elderly Aged 75 and older is to deliver the relevant document to the Order of the Ministry of Health, Labour and Welfare that has requested the delivery of the relevant document, and provide the matters to be stated in the relevant document by electronic or magnetic means to the insured that has requested the provision of the relevant matters by electronic or magnetic means, pursuant to the provisions of Order of the insured.
(6) If a notification under Articles 22 through 24, Article 25, Article 30-46, or Article 30-47 of the Act for Basic Register of Residents (Act No. 81 of 1967) has been filed (but only if a supplementary note under Article 28-2 of that Act has been added to a document connected with that notification), the notification under paragraph (1) is deemed to have been filed based on the same grounds as the notification.
(7) Beyond what is provided for in the preceding paragraphs, matters necessary for notification concerning insured and confirmation concerning the qualifications of insured are specified by Order of the Order of the Ministry of Health, Labour and Welfare.
(Special Provisions for insured During Hospitalization, Admission or Occupancy in Hospitals)
Article 55  (1) Notwithstanding the provisions of Article 50, an insured that is found to have changed its address to a place where hospitals, clinics, or facilities provided in the following items (hereinafter referred to as "hospitals, etc." in this Article) are located due to hospitalization, admission, or occupancy set forth in the following items (hereinafter referred to as "hospitalization, etc." in this Article) (excluding a person who is deemed, pursuant to the provisions of paragraph (1) of the following Article, to be an insured for late-stage elderly medical care provided by a Association of Medical Care Systems for the Elderly Aged 75 and older of the previous domicile provided in the same paragraph), and is found to have been domiciled in the area of another Association of Medical Care Systems for the Elderly Aged 75 and older (meaning a Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older where the relevant hospitals, etc. are located) at the time of hospitalization, etc. in the relevant hospitals, etc., is an insured for late-stage elderly medical care provided by the relevant other Association of Medical Care Systems for the Elderly Aged 75 and older; provided, however, that this does not apply to an pharmacy that is continuously hospitalized, etc. in two or more hospitals, etc., which is found to have changed its address to a place where a hospital, etc. where the relevant person is currently hospitalized, etc. (hereinafter referred to as the "current hospitalization hospital, etc." in this Article) was immediately hospitalized, etc. immediately before the hospitalization, etc. (hereinafter referred to as the "immediately preceding hospitalization hospital, etc." in this paragraph) and to a place where the immediately preceding hospitalization hospital, etc. and the current hospitalization hospital, etc. are located sequentially due to the hospitalization, etc. in each of the immediately preceding hospitalization hospital, etc. and the current hospitalization hospital, etc. (referred to as a "specified continuous hospitalization pharmacy" in the following paragraph): insured insured:
(i) admission to a hospital or clinic;
(ii) admission to a Support Facility for Persons with Disabilities prescribed in Article 5, paragraph (11) of the Act on Providing Comprehensive Support for the Daily Life and Life in Society of Persons with Disabilities (Act No. 123 of 2005) or a facility specified by order of the competent ministry as referred to in paragraph (1) of that Article;
(iii) admission to a facility established by the Incorporated Administrative Agency National Center for Severe intellectually disabled person Nozominosono pursuant to the provisions of Article 11, item (i) of the Act on the Incorporated Administrative Agency National Center for Severe intellectually disabled person Nozominosono (Act No. 167 of 2002);
(iv) admission to a nursing home for the elderly or an intensive care home for the elderly as prescribed in Article 20-4 or 20-5 of the Act on Social Welfare for the Elderly (Act No. 133 of 1963) (limited to the case where admission measures pursuant to the provisions of Article 11, paragraph (1), item (i) or (ii) of the same Act have been taken);
(v) long-Term Care Insurance Act: moving into a specified facility as prescribed in Article 8, paragraph (11) or admission into a nursing care insurance facilities as prescribed in paragraph (25) of the same Article.
(2) Notwithstanding the provisions of Article 50, an insured for specified continuous hospitalization, etc. that is set forth in each of the following items is an insured for late-stage elderly medical care provided by a Association of Medical Care Systems for the Elderly Aged 75 and older specified in each of the following items:
(i) an insured whose address is found to have been sequentially changed to the location of two or more hospitals, etc., due to the fact that the person was hospitalized, etc. in each of the hospitals, etc., continuously, and who is found to have been domiciled in the area of another Association of Medical Care Systems for the Elderly Aged 75 and older (meaning a Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older where the current hospital, etc. is located) at the time of the hospitalization, etc. in the first of the two or more hospitals, etc.: the relevant other Association of Medical Care Systems for the Elderly Aged 75 and older;
(ii) an insured that is found to have changed its address from a place other than the location of one of the two or more hospitals, etc. in which the relevant person has been continuously hospitalized, etc. to a place where the relevant other hospital, etc. is located (hereinafter referred to as a "specified change of address" in this item) as a result of being continuously hospitalized, etc. from one of the hospitals, etc. to another (hereinafter referred to as "continuous hospitalization, etc." in this item), and that is found to have been domiciled in the area of another Association of Medical Care Systems for the Elderly Aged 75 and older (meaning a Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older where the current hospital, etc. is located) at the time of the last specified change of address pertaining to continuous hospitalization, etc.: the relevant other Association of Medical Care Systems for the Elderly Aged 75 and older.
(3) Hospitals, etc. in which an insured to which the provisions of the preceding two paragraphs are applied is Hospitalized, etc. must provide necessary cooperation to the Association of Medical Care Systems for the Elderly Aged 75 and older where the Hospitals, etc. are located and the Association of Medical Care Systems for the Elderly Aged 75 and older which provides Old-Old Healthcare to the insured.
(Special Provisions for Persons Covered by the Provisions of Article 116-2 of the National Health Insurance Act)
Article 55-2  (1) Notwithstanding the provisions of Article 50, if a person (limited to a person who is 65 years of age or older and under 75 years of age in the case referred to in item (ii)) who is a Article 116-2, paragraphs (1) and (2) covered by national health insurance to which the provisions of the insured of the National Health Insurance Act are applied and who is domiciled in the area of a Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older to which a municipality that is deemed to have domicile pursuant to these provisions (hereinafter referred to as the "municipality of the previous domicile" in this paragraph) belongs (limited to a person who is 65 years of age or older and under 75 years of age in the case referred to in item (ii)) has come to fall under any of the following items, the person is to be a insured for medical care for the elderly provided by the Association of Medical Care Systems for the Elderly Aged 75 and older to which the municipality of the previous domicile belongs (referred to as the "Association of Medical Care Systems for the Elderly Aged 75 and older of the previous domicile" in item (ii) and the following paragraph). In this case, the insured acquires the eligibility from the day on which the person comes to fall under any of the following items, notwithstanding the provisions of Article 52:
(i) when the person has reached 75 years of age;
(ii) if the person has been certified by the Association of Medical Care Systems for the Elderly Aged 75 and older of the previous domicile as having a disability of a degree of severity specified by Cabinet Order as referred to in Article 50, item (ii), pursuant to the provisions of Prefectural or Municipal Order of the Ministry of Health, Labour and Welfare.
(2) The provisions of the preceding Article apply mutatis mutandis to a person who is deemed to be a insured for Old-Old Healthcare provided by the Association of Medical Care Systems for the Elderly Aged 75 and older of the Previous Domicile pursuant to the provisions of the preceding paragraph. In this case, the necessary technical replacement of terms is specified by Cabinet Order.
Section 3 Old-Old Age medical care benefit
Subsection 1 General Rules
(Types of medical care benefit for Old-Old Persons)
Article 56  The benefits under this Act pertaining to an insured (hereinafter referred to as an "old-old medical care benefit") are as follows:
(i) benefits for medical treatment, and payment of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, and transport expenses;
(ii) payment of high-cost medical expenses and Sizable medical and nursing expenses;
(iii) beyond what is set forth in the preceding two items, benefits provided pursuant to the provisions of Prefectural or Municipal Ordinance of the Association of Medical Care Systems for the Elderly Aged 75 and older.
(Coordination with Benefits Related to Medical Services Provided by Other Laws and Regulations)
Article 57  (1) Benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, or transport expenses are not paid if, with respect to the relevant illness or injury in insured, the relevant person is eligible for benefits for medical treatment pursuant to the provisions of the industrial accident compensation insurance Act (Act No. 50 of 1947), for medical treatment compensation pursuant to the provisions of the Multi-Business Worker medical compensation benefit or medical treatment benefit, pursuant to the provisions of the National Public Officers' Accident Compensation Act (Act No. 191 of 1951; including as applied mutatis mutandis pursuant to other Acts), for medical treatment compensation pursuant to the provisions of the local public employee Accident Compensation Act (Act No. 121 of 1967) or the provisions of Prefectural Ordinances based on the same Act, or benefits related to medical care pursuant to other Acts specified by Cabinet Order, or is eligible for benefits equivalent to the respective benefits pursuant to the provisions of Long-Term Care Insurance Act, or if benefits related to medical care have been medical treatment benefit.
(2) If benefits under a law or regulation as prescribed in the preceding paragraph are benefits in kind related to medical care, and co-payment or collection of actual costs has been made for the benefits and the amount of co-payment or collection of actual costs exceeds the amount of co-payment under this Act if the benefits are considered to have been provided as benefits for medical treatment under this Act, or if benefits under a law or regulation as prescribed in the same paragraph (excluding a Long-Term Care Insurance Act) are payment of medical expenses and the amount paid is less than the amount of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, or transport expenses if dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, or transport expenses are to be paid for the medical treatment under this Act, the Association of Medical Care Systems for the Elderly Aged 75 and older must pay the difference between those amounts to the insured.
(3) In the case referred to in the preceding paragraph, when a insured receives the medical treatment at a medical institution providing services covered by health insurance, etc. (meaning a medical institution providing services covered by health insurance prescribed in Article 63, paragraph (3), item (i) of the Health Insurance Act (hereinafter referred to as a "medical institution providing services covered by health insurance") or pharmacies providing services covered by health insurance; the same applies hereinafter), the Association of Medical Care Systems for the Elderly Aged 75 and older may, on behalf of the insured, pay to the medical institution providing services covered by health insurance, etc. the expenses required for the medical treatment payable by the insured to the medical institution providing services covered by health insurance, etc., within the limit of the amount payable to the insured pursuant to the provisions of the preceding paragraph.
(4) When expenses have been paid to a medical institution providing services covered by health insurance, etc. pursuant to the provisions of the preceding paragraph, the payment under paragraph (2) is deemed to have been made to insured to the extent of the payment.
(Right to Demand Compensation for)
Article 58  (1) In the case where grounds for claim payment are caused by an act of a third person, when a Association of Medical Care Systems for the Elderly Aged 75 and older provides a medical care benefit for the old-old (including payment of the difference pursuant to the provisions of paragraph (2) of the preceding Article; the same applies hereinafter), the acquires the right to claim compensation for loss or damage held by the insured against the third person to the extent of the value of the medical care benefit for the old-old (when the medical care benefit for the old-old is a benefit for medical treatment, the amount obtained by deducting, from the amount of expenses required for the benefit for medical treatment, the amount equivalent to the amount of co-payment to be borne by the insured with regard to the benefit for medical treatment; the same applies in paragraph (1) of the following Article).
(2) In the case referred to in the preceding paragraph, if a person who is to receive an old-old medical care benefit has received compensation for loss or damage from a third party for the same reason, the Association of Medical Care Systems for the Elderly Aged 75 and older is exempt from the responsibility to provide the old-old medical care benefit to the extent of the amount of the compensation.
(3) A Association of Medical Care Systems for the Elderly Aged 75 and older may entrust its affairs concerning the collection or receipt of compensation for damage pertaining to the right to claim acquired pursuant to the provisions of paragraph (1) to a federation of national health insurance associations specified by Order of the Ministry of Health, Labour and Welfare.
(Collection of Fraudulent Gains)
Article 59  (1) If a person receives an old-old medical care benefit by deception or other wrongful acts, the Association of Medical Care Systems for the Elderly Aged 75 and older may collect all or part of the value of the old-old medical care benefit from that person.
(2) In the case referred to in the preceding paragraph, when a physician providing health insurance treatment at a medical institution providing services covered by health insurance or an attending physician as prescribed in Article 78, paragraph (1) has made a false entry on a written diagnosis to be submitted to the Association of Medical Care Systems for the Elderly Aged 75 and older, and as a result, the late-stage elderly medical care benefit has been provided, the Association of Medical Care Systems for the Elderly Aged 75 and older may order the physician providing health insurance treatment or the attending physician to pay the money to be collected pursuant to the preceding paragraph jointly and severally with the person who has received the late-stage elderly medical care benefit.
(3) When a medical institution providing services covered by health insurance, etc. or a designated home-nursing provider (meaning the designated home-nursing provider prescribed in Article 88, paragraph (1) of the Health Insurance Act; the same applies hereinafter) has received, by deception or other wrongful acts, any payment of expenses relating to benefits for medical treatment or any payment pursuant to the provisions of Article 74, paragraph (5) (including as applied mutatis mutandis pursuant to Article 75, paragraph (7), Article 76, paragraph (6), and Article 78, paragraph (8)), the Association of Medical Care Systems for the Elderly Aged 75 and older may have the medical institution providing services covered by health insurance, etc. or the designated home-nursing provider return the amount so paid and, in addition, pay the amount obtained by multiplying the amount to be returned by forty one hundredth (40 / 100).
(Submission of Documents)
Article 60  If a Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary in relation to an old-old medical care benefit, the family court may order the insured, the person who used to be the insured, or the person who receives an old-old medical care benefit to submit or present documents or other objects, or may have its personnel question or diagnose the person.
(Presentation of Medical Records)
Article 61  (1) The Minister of Health, Labour and Welfare or the prefectural governor, when finding it necessary in relation to a medical care benefit for the old-old, may order physicians, dentists, pharmacists, or persons who provided medical care or those who employ them to make a report or present medical records, books and documents, and other objects, or may have their personnel question them, with regard to the medical care, provision of drugs, or medical treatment provided by them.
(2) The Minister of Health, Labour and Welfare or the prefectural governor may, when finding it necessary, order a insured or a former insured that received payment of benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses to make a report or have their official ask questions about the content of medical care, prescription or designated home-nursing pertaining to the payment of the benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses.
(3) The provisions of Article 16-7, paragraph (2) apply mutatis mutandis to questions pursuant to the provisions of the preceding two paragraphs, and the provisions of paragraph (3) of the same Article apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding two paragraphs.
(Protection of the Right to Receive Benefits)
Article 62  The right to receive an old-old medical care benefit may not be transferred, pledged as collateral, or levied.
(Prohibition of Taxation and Other Public Charges)
Article 63  Taxes and other public charges may not be imposed on the basis of money and goods received as payment as a medical care benefit for Old-Old Age.
Subsection 2 Benefits for Medical Treatment and Payment of Dietary Treatment Expenses for Inpatients
Division 1 Benefits for Medical Treatment, and Payment of Dietary Treatment Expenses for Inpatients, Living Support Expenses for Inpatients, Medical Expenses Combined with Treatment Outside Insurance Coverage, and Medical Expenses
(Benefits for Medical Treatment)
Article 64  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older provides the following benefits for medical treatment with respect to sickness and injury of a insured; provided, however, that this does not apply during any period to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article apply to the insured:
(i) medical examination;
(ii) provision of medicines or treatment materials;
(iii) treatment, surgery, or other medical treatment;
(iv) management of in-home medical treatment and care and other nursing involved in the medical treatment;
(v) admission to a hospital or clinic, and care and other nursing incidental to medical treatment there.
(2) Benefits for the following medical treatment are not to be included in the benefits referred to in the preceding paragraph:
(i) medical treatment consisting of the provision of meals, which is provided in combination with the medical treatment listed in item (v) of the preceding paragraph (excluding hospitalization in a sanatorium ward provided for in Article 7, paragraph (2), item (iv) of the Medical Care Act and care and other nursing incidental to the medical treatment (hereinafter referred to as "long-term hospitalization and medical treatment")) (hereinafter referred to as "dietary treatment");
(ii) the following types of medical treatment given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (limited to long-term inpatient treatment) (hereinafter referred to as "living support"):
(a) medical treatment consisting of the provision of meals;
(b) medical treatment consisting of the creation of an appropriate environment for medical treatment in terms of temperature, lighting and water supply;
(iii) medical treatment using advanced medical care techniques specified by the Minister of Health, Labour and Welfare and other medical treatment specified by the Minister of Health, Labour and Welfare as medical treatment for which it is necessary to evaluate whether or not it should be subject to the benefits referred to in the preceding paragraph from the viewpoint of efficiently providing appropriate medical care (excluding patient-requested treatment referred to in the following item) (hereinafter referred to as "evaluation treatment");
(iv) medical treatment using advanced medical technology, which is specified by the Minister of Health, Labour and Welfare as medical treatment for which it is necessary to evaluate, from the viewpoint of efficiently providing appropriate medical care, whether or not it should be subject to benefits as set forth in the preceding paragraph, based on a request from a person who intends to receive the medical treatment (hereinafter referred to as "patient-requested treatment");
(v) the provision of a special sickroom pertaining to the selection of a insured and other medical treatment specified by the Minister of Health, Labour and Welfare (hereinafter referred to as "selective treatment");
(3) When an insured intends to receive the benefits referred to in paragraph (1), it is to receive the benefits referred to in paragraph (1) after being confirmed as an Association of Medical Care Systems for the Elderly Aged 75 and older by a medical institution providing services covered by health insurance, etc. selected by it (meaning that a person who intends to receive medical treatment from a medical institution providing services covered by health insurance, etc. or a person who intends to receive designated home-nursing as prescribed in Article 78, paragraph (1) inquires about the data pertaining to the eligibility of the insured (including data necessary for claiming the expenses pertaining to the payment of insurance proceeds) by a method specified by Order of the Ministry of Health, Labour and Welfare, such as a method of transmitting an electronic certificate for certification of users (meaning an electronic certificate for certification of users as prescribed in Article 22, paragraph (1) of the Act on the Certification Business of Medical Institutions Pertaining to Electronic Signatures, etc. (Act No. 153 of 2002)) recorded on an individual number card (meaning an individual number card as prescribed in Article 2, paragraph (7) of the Act on the Use of Numbers to Identify a Specific Individual in Administrative Procedures (Act No. 27 of 2013)), and receives a response from the Association of Medical Care Systems for the Elderly Aged 75 and older by a method using an electronic data processing system or other information and communications technology, provides the data to the medical institution providing services covered by health insurance, etc. or designated home-nursing provider, and receives confirmation from the medical institution providing services covered by health insurance, etc. or designated home-nursing provider that the person is an insured; the same applies hereinafter) or other method specified by Order of the Ministry of Health, Labour and Welfare (hereinafter referred to as "electronic certification, etc."); provided, however, that the confirmation is not required when the case falls under a case specified by Order of the Ministry of Health, Labour and Welfare. insured Japan Agency for Local Authority Information Systems.
(4) The request referred to in paragraph (2), item (iv) is to be made to the Minister of Health, Labour and Welfare, pursuant to the provisions of the Minister of Health, Labour and Welfare, by attaching a written opinion of the organizer of the core hospital for clinical research prescribed in Article 4-3 of the Medical Care Act (limited to medical institutions providing services covered by health insurance) which provides the medical treatment pertaining to the request and other necessary documents.
(5) If the Minister of Health, Labour and Welfare receives a request referred to in paragraph (2), item (iv), the Minister is to promptly review the request, and if the medical treatment related to the request is found to be that which requires the evaluation referred to in the same item, the Minister is to specify the medical treatment as patient-requested treatment.
(6) If the Minister of Health, Labour and Welfare has determined that the medical treatment pertaining to the application prescribed in paragraph (2), item (iv) pursuant to the provisions of the preceding paragraph is patient-requested treatment, the Minister is to promptly notify the person who has made the application to that effect.
(7) If the Minister of Health, Labour and Welfare has reviewed the request referred to in paragraph (2), item (iv) pursuant to the provisions of paragraph (5) and has determined that the medical treatment pertaining to the request is not to be specified as patient-requested treatment, the Minister is to promptly notify the person who has made the request to that effect by giving the reason.
(Responsibilities of Medical Institutions Providing Services Covered by Health Insurance)
Article 65  A medical institution providing services covered by health insurance, etc. or a physician providing health insurance treatment, etc. (meaning a physician providing health insurance treatment or pharmacist filling health insurance prescriptions as prescribed in Article 64 of the Health Insurance Act; the same applies hereinafter) must handle or take charge of medical treatment benefits for medical care for elderly people in accordance with the standards for handling and taking charge of medical treatment benefits as set forth in Article 71, paragraph (1).
(Guidance by the Minister of Health, Labour and Welfare or Prefectural Governors)
Article 66  (1) Guidance by the Minister of Health, Labour and Welfare or the prefectural governor must be received by Health Insurance-Covered Medical Institutions, etc. with regard to benefits for medical treatment, and by Health Insurance-Covered Physicians, etc. with regard to medical care or prescription of Old-Old Healthcare.
(2) The Minister of Health, Labour and Welfare or the prefectural governor, when providing the guidance prescribed in the preceding paragraph and finding it necessary, is to have a person with relevant expertise related to medical care or prescription services attend in accordance with the designation by the relevant organization; provided, however, that this does not apply when the relevant organization makes no designation or when the designated person does not attend.
(Co-payment)
Article 67  (1) A person who receives benefits for medical treatment at or from a medical institution providing services covered by health insurance pursuant to the provisions of Article 64, paragraph (3) must pay, in accordance with the categories of the cases listed in the following items, the amount obtained by multiplying the amount calculated in accordance with the standards for calculation of the amount of expenses incurred in providing the benefits for medical treatment set forth in Article 70, paragraph (2) or Article 71, paragraph (1) by the ratio specified in the relevant item, as the person's co-payment to the medical institution providing services covered by health insurance:
(i) in cases other than the cases set forth in the following item and item (iii): ten percent;
(ii) if the amount of income calculated pursuant to Cabinet Order for a person receiving benefits for medical treatment or for a insured or other person specified by Cabinet Order who is another Household Member of the household to which the person belongs is not less than the amount specified by Cabinet Order (other than in the case set forth in the following item): 20 percent;
(iii) if the amount of income calculated pursuant to Cabinet Order for a person receiving the benefits for medical treatment or for a insured or any other person specified by Cabinet Order who is another Household Member of the household to which the person belongs exceeds the amount specified by Cabinet Order referred to in the preceding item: 0.30.
(2) A medical institution providing services covered by health insurance, etc. is to receive the co-payment set forth in the preceding paragraph (when the measure set forth in Article 69, paragraph (1), item (i) has been taken, the co-payment after the reduction), and when a insured fails to pay all or part of the co-payment despite the efforts of the medical institution providing services covered by health insurance, etc. to receive the payment with the same care as a prudent manager, the Association of Medical Care Systems for the Elderly Aged 75 and older may, based on a request by the medical institution providing services covered by health insurance, etc., impose a disposition on the insurer in accordance with the same rules as those for the money to be collected pursuant to the provisions of this Act.
Article 68  In the case of making co-payment pursuant to the provisions of paragraph (1) of the preceding Article, if the amount of co-payment includes a fraction less than five yen, the fraction is to be rounded down, and if the amount includes a fraction not less than five yen but less than ten yen, the fraction is to be rounded up to the nearest ten yen.
Article 69  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older may take the following measures with respect to an Order of the Ministry of Health, Labour and Welfare which is subject to disasters or other special circumstances specified by the insured and for which it is found difficult to make co-payment to a medical institution providing services covered by health insurance, etc. pursuant to the provisions of Article 67, paragraph (1):
(i) to reduce the amount of co-payment;
(ii) exemption from co-payment;
(iii) to decide to collect co-payment directly from the insured person in lieu of co-payment to the medical institution providing services covered by health insurance, etc., and to suspend such collection.
(2) Notwithstanding the provisions of Article 67, paragraph (1), in the case of an insured that has received the measures set forth in the preceding paragraph, it is sufficient for the insured to pay the reduced amount of co-payment to the medical institution providing services covered by health insurance, etc., and in the case of an insured that has received the measures set forth in item (ii) or item (iii) of the preceding paragraph, it is not required to pay the co-payment to the medical institution providing services covered by health insurance, etc.
(3) The provisions of the preceding Article apply mutatis mutandis to the payment of co-payment in the case referred to in the preceding paragraph.
(Medical Fees of Medical Institutions Providing Services Covered by Health Insurance)
Article 70  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older is to pay expenses related to benefits for medical treatment to medical institutions providing services covered by health insurance, etc., and the amount of expenses which a medical institution providing services covered by health insurance, etc. may claim from a Association of Medical Care Systems for the Elderly Aged 75 and older related to benefits for medical treatment is the amount calculated by deducting the amount of co-payment to be paid to the relevant medical institution providing services covered by health insurance, etc. with respect to the relevant benefits for medical treatment from the amount of expenses required for benefits for medical treatment calculated in accordance with the standards for calculation of the amount of expenses required for benefits for medical treatment set forth in paragraph (1) of the following Article.
(2) A Association of Medical Care Systems for the Elderly Aged 75 and older may, with the authorization of the prefectural governor, specify otherwise in a contract with a medical institution providing services covered by health insurance, etc. with regard to the expenses required for the benefits for medical treatment set forth in the preceding paragraph pertaining to the benefits for medical treatment provided at the medical institution providing services covered by health insurance, etc., within the scope of the amount calculated pursuant to the provisions of the same paragraph.
(3) When a medical institution providing services covered by health insurance, etc. requests payment of expenses related to benefits for medical treatment, the Association of Medical Care Systems for the Elderly Aged 75 and older is to make payment after conducting an examination in light of the standards for treatment and responsibility for benefits for medical treatment as set forth in paragraph (1) of the following Article, the standards for calculation of the amount of expenses required for benefits for medical treatment, and the provisions of the preceding paragraph.
(4) The Association of Medical Care Systems for the Elderly Aged 75 and older may entrust affairs concerning the examination and payment under the provisions of the preceding paragraph to the Reimbursement Services or the NHI Federations.
(5) A federation of national health insurance associations that is entrusted pursuant to the provisions of the preceding paragraph may entrust the affairs concerning the examination entrusted thereto, which pertain to the examination of medical bills specified by the Minister of Health, Labour and Welfare, to a corporation designated by the Minister of Health, Labour and Welfare as prescribed in Article 45, paragraph (6) of the National Health Insurance Act (hereinafter referred to as a "designated corporation").
(6) A designated corporation that has been entrusted with the affairs concerning the review of medical bills specified by the Minister of Health, Labour and Welfare pursuant to the provisions of the preceding paragraph must have the review of the medical bills conducted by a person who satisfies the requirements specified by Order of the Order of the Ministry of Health, Labour and Welfare.
(7) Beyond what is provided for in each of the preceding paragraphs, necessary matters concerning claims for expenses incurred in providing medical treatment at medical institutions providing services covered by health insurance, etc. are specified by Order of the Order of the Ministry of Health, Labour and Welfare.
(Standards for Benefits for Medical Treatment)
Article 71  (1) The standards concerning the treatment and assignment of benefits for medical treatment and the standards concerning the calculation of the amount of expenses required for benefits for medical treatment are to be determined by the Minister of Health, Labour and Welfare after hearing the opinions of the Central Social Insurance Medical Council.
(2) Notwithstanding the provisions of Article 2, paragraph (1) of the Social Insurance Medical Council Act (Act No. 47 of 1950), the Central Social Insurance Medical Council may deliberate on the particulars for which it has been asked for its opinion pursuant to the provisions of the preceding paragraph, and submit a report in writing, as well as make its own proposal in writing to the Minister of Health, Labour and Welfare with regard to the particulars prescribed in the same paragraph.
(Reports of Medical Institutions Providing Services Covered by Health Insurance)
Article 72  (1) The Minister of Health, Labour and Welfare or the prefectural governor, when they find it necessary in relation to benefits for medical treatment, may order a medical institution providing services covered by health insurance, etc., an establisher or administrator of a medical institution providing services covered by health insurance, etc., a physician providing health insurance treatment, etc., or any other person who was an employee (hereinafter referred to as a "former establisher, etc." in this paragraph) to make a report or submit or present medical records or other books and documents, request the appearance of an establisher or administrator of a medical institution providing services covered by health insurance, etc., a physician providing health insurance treatment, etc., or any other employee (including a former establisher, etc.), or have their official ask relevant persons questions or inspect facilities, medical records, books and documents, or any other articles of the medical institution providing services covered by health insurance, etc.
(2) The provisions of Article 16-7, paragraph (2) and Article 66, paragraph (2) apply mutatis mutandis to questions and inspections pursuant to the provisions of the preceding paragraph, and the provisions of Article 16-7, paragraph (3) apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding paragraph.
(3) When a prefectural governor finds it necessary for a medical institution providing services covered by health insurance, etc. to render a disposition pursuant to the provisions of Article 80 of the Health Insurance Act with regard to benefits for medical treatment pursuant to the provisions of this Act, or when a prefectural governor finds it necessary for a physician providing health insurance treatment, etc. to render a disposition pursuant to the provisions of Article 81 of the Health Insurance Act with regard to medical care or prescription pursuant to the provisions of this Act, the prefectural governor must notify the Minister of Health, Labour and Welfare to that effect, with the reason attached thereto.
(Mutatis Mutandis Application of the Health Insurance Act)
Article 73  The provisions of Article 64 of the Health Insurance Act apply mutatis mutandis to benefits for medical treatment under the provisions of this Act.
(Dietary Treatment Expenses for Inpatients)
Article 74  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older pays dietary treatment expenses for inpatients to a insured (excluding pharmacies receiving long-term in-patient treatment (referred to as a "long-term in-patient insured" in paragraph (1) of the following Article); hereinafter the same applies in this Article) for expenses required for dietary treatment received by the insured in combination with benefits for medical treatment listed in Article 64, paragraph (1), item (v) at or from a medical institution providing services covered by health insurance, etc. (excluding pharmacies providing services covered by health insurance; hereinafter the same applies in this Article and the following Article) selected by the insured; provided, however, that this does not apply during any period to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article apply to the insured.
(2) The amount of dietary treatment expenses for inpatients is the amount calculated by deducting the amount specified by the Minister of Health, Labour and Welfare in consideration of the status of food expenses for an average household budget and the average amount of expenses required to provide meals at a specified nursing care insurance facilities, etc. (meaning a specified facility, etc. for insured long-term care prescribed in Article 51-3, paragraph (1) of Long-Term Care Insurance Act) (for a person specified by Order of the Ministry of Health, Labour and Welfare in consideration of income status and other circumstances, a separately determined amount; hereinafter referred to as the "standard co-payment for dietary treatment") from the amount of expenses calculated based on the standards specified by the Minister of Health, Labour and Welfare in consideration of the average amount of expenses required for the dietary treatment (when the calculated amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of expenses actually incurred).
(3) If the circumstances pertaining to the matters to be taken into consideration have significantly changed after the Minister of Health, Labour and Welfare has determined the standard co-payment amount for dietary treatment, the Minister must promptly revise the amount.
(4) Medical institutions providing services covered by health insurance and physicians, etc. filling health insurance prescriptions (excluding pharmacists filling health insurance prescriptions; the same applies in paragraph (4) of the following Article) must handle or take charge of medical treatment pertaining to dietary treatment expenses for inpatients in accordance with the standards for handling and taking charge of medical treatment pertaining to dietary treatment expenses for inpatients specified by the Minister of Health, Labour and Welfare.
(5) When a insured has received dietary treatment at or from a medical institution providing services covered by health insurance, etc., the Association of Medical Care Systems for the Elderly Aged 75 and older may, on behalf of the insured, pay to the medical institution providing services covered by health insurance, etc. expenses incurred for the dietary treatment payable by the insured to the medical institution providing services covered by health insurance, etc., within the limit of the amount payable to the insured as expenses for dietary treatment for inpatients.
(6) If a payment under the provisions of the preceding paragraph is made, it is deemed that dietary treatment expenses for inpatients are paid to the insured.
(7) Upon accepting payment of expenses incurred for dietary treatment, a medical institution providing services covered by health insurance, etc. must, pursuant to the provisions of Order of the insured, deliver receipts to the Order of the Ministry of Health, Labour and Welfare which has made the payment.
(8) The Minister of Health, Labour and Welfare must hear the opinions of the Central Social Insurance Medical Council in advance, when the Minister intends to establish standards under the provisions of paragraph (2) and standards concerning the treatment and taking charge of medical treatment pertaining to dietary treatment expenses for inpatients prescribed in paragraph (4).
(9) The provisions of Article 71, paragraph (2) apply mutatis mutandis to the authority of the Central Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.
(10) The provisions of Article 64 of the Health Insurance Act and Article 64, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), and Article 72 of this Act apply mutatis mutandis to dietary treatment received at or from a medical institution providing services covered by health insurance and to the payment of dietary treatment expenses for inpatients associated with that treatment. In such a case, Cabinet Order provides for the necessary technical replacement of terms in connection with these provisions.
(Living Support Expenses for Inpatients)
Article 75  (1) With respect to expenses required for living support received by a long-term inpatient insured in combination with benefits for medical treatment listed in Article 64, paragraph (1), item (v) at or from a medical institution providing services covered by health insurance, etc. selected by the long-term inpatient insured, the Association of Medical Care Systems for the Elderly Aged 75 and older pays living support expenses for inpatients to the long-term inpatient insured; provided, however, that this does not apply during any period to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article apply to the long-term inpatient inpatient ward.
(2) The amount of living support expenses for inpatients is the amount calculated by deducting the amount specified by the Minister of Health, Labour and Welfare in consideration of the amount equivalent to the base cost for food expenses prescribed in Article 51-3, paragraph (2), item (i) of the Long-Term Care Insurance Act and the base cost for residence expenses prescribed in item (ii) of the same paragraph with regard to the status of food expenses and light, heating and water utility costs for an average household budget and the expenses required for living support at hospitals and clinics (for a person specified by the Order of the Ministry of Health, Labour and Welfare in consideration of the status of income, the degree of pathological condition, the content of treatment and other circumstances, a separately specified amount; hereinafter referred to as the "standard co-payment for living support") from the amount calculated based on the standards specified by the Minister of Health, Labour and Welfare in consideration of the average expenses required for the living support (when the calculated amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred in the living support).
(3) When the circumstances pertaining to the matters to be taken into consideration have significantly changed after the Minister of Health, Labour and Welfare has determined the standard co-payment amount for living support, the Minister must promptly revise the amount.
(4) Medical institutions providing services covered by health insurance, etc. and physicians providing services covered by health insurance, etc. must handle or take charge of medical treatment pertaining to living support expenses for inpatients in accordance with the standards for handling and taking charge of medical treatment pertaining to living support expenses for inpatients specified by the Minister of Health, Labour and Welfare.
(5) The Minister of Health, Labour and Welfare must hear the opinions of the Central Social Insurance Medical Council in advance, when the Minister intends to establish standards under the provisions of paragraph (2) and standards concerning the treatment and assignment of medical treatment pertaining to living support expenses for inpatients prescribed in the preceding paragraph.
(6) The provisions of Article 71, paragraph (2) apply mutatis mutandis to the authority of the Central Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.
(7) The provisions of Article 64 of the Health Insurance Act and Article 64, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), Article 72, and paragraphs (5) through (7) of the preceding Article of this Act apply mutatis mutandis to living support received at or from a medical institution providing services covered by health insurance and to the payment of living support expenses for inpatients associated with the living support. In such a case, Cabinet Order provides for the necessary technical replacement of terms in connection with these provisions.
(Medical Expenses Combined with Treatment Outside Insurance Coverage)
Article 76  (1) When an insured receives evaluation treatment, patient-requested treatment, or selective treatment at or from a medical institution providing services covered by health insurance, etc. that it has selected, the Association of Medical Care Systems for the Elderly Aged 75 and older pays medical expenses combined with treatment outside insurance coverage to the insured for the expenses required for the treatment; provided, however, that this does not apply during any period to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article apply to the insured.
(2) The amount of medical expenses combined with treatment outside insurance coverage is the amount listed in item (i) (if the medical treatment includes dietary treatment, the sum of the amount and the amount listed in item (ii), and if the medical treatment includes living support, the sum of the amount and the amount listed in item (iii)):
(i) the amount calculated by deducting, from the amount of expenses calculated for the medical treatment (excluding dietary treatment and living support) in accordance with the standards specified by the Minister of Health, Labour and Welfare in consideration of the standards for calculation of the amount of expenses required for benefits for medical treatment prescribed in Article 71, paragraph (1) (when the 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 the amount of expenses by the applicable ratio specified in the items of Article 67, paragraph (1) in accordance with the categories of the cases listed in the items of the same paragraph (when the measures listed in the items of Article 69, paragraph (1) should be taken with respect to the co-payment set forth in the same paragraph for benefits for medical treatment, the amount calculated as if the measures were taken);
(ii) the amount calculated by deducting the amount of standard co-payment for dietary treatment from the amount of expenses calculated for the dietary treatment in accordance with the standards specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 74, paragraph (2) (when the calculated amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of expenses actually incurred);
(iii) the amount calculated by deducting the amount of standard co-payment for living support from the amount of expenses calculated for the living support in accordance with the standards specified by the Minister of Health, Labour and Welfare pursuant to the provisions of paragraph (2) of the preceding Article (when the calculated amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred).
(3) Medical institutions providing services covered by health insurance, etc. and physicians providing services covered by health insurance, etc. must handle or take charge of medical treatment covered by medical expenses combined with treatment outside insurance coverage in accordance with the standards for handling and taking charge of medical treatment covered by medical expenses combined with treatment outside insurance coverage specified by the Minister of Health, Labour and Welfare.
(4) The Minister of Health, Labour and Welfare must hear the opinions of the Central Social Insurance Medical Council in advance, when the Minister intends to establish standards for evaluation treatment (excluding those pertaining to advanced medical care techniques prescribed in Article 64, paragraph (2), item (iii)), selective treatment, standards pursuant to the provisions of paragraph (2), item (i), and standards concerning treatment and taking charge of medical treatment pertaining to medical expenses combined with treatment outside insurance coverage prescribed in the preceding paragraph.
(5) The provisions of Article 71, paragraph (2) apply mutatis mutandis to the authority of the Central Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.
(6) The provisions of Article 64 of the Health Insurance Act and Article 64, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), Article 72, and Article 74, paragraphs (5) through (7) of this Act apply mutatis mutandis to payment of evaluation treatment, patient-requested treatment, and selective treatment received at or from a medical institution providing services covered by health insurance, and medical expenses combined with treatment outside insurance coverage associated with the relevant treatment. In this case, the necessary technical replacement of terms in these provisions is specified by Cabinet Order.
(7) The provisions of Article 68 apply mutatis mutandis to the payment of the amount calculated by deducting, from the amount of expenses calculated pursuant to the provisions of paragraph (2) for the medical treatment in the case set forth in Article 74, paragraph (5) as applied mutatis mutandis pursuant to the provisions of the preceding paragraph (when the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred), the amount payable as medical expenses combined with treatment outside insurance coverage with respect to the expenses incurred in the medical treatment.
(Medical Expenses)
Article 77  (1) When a Association of Medical Care Systems for the Elderly Aged 75 and older finds it difficult to pay benefits for medical treatment, or expenses for dietary treatment for inpatients, living support expenses for inpatients, or medical expenses combined with treatment outside insurance coverage (hereinafter referred to as "benefits for medical treatment, etc." in this paragraph and the following paragraph), or when a insured has received any medical care, medication or treatment at or from hospitals, clinics, pharmacies or any other persons other than medical institutions providing services covered by health insurance, etc. and the Association of Medical Care Systems for the Elderly Aged 75 and older finds it unavoidable, it may pay medical expenses in lieu of benefits for medical treatment, etc.; provided, however, that this does not apply during any period for which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article are applied to the insured.
(2) In cases where a Association of Medical Care Systems for the Elderly Aged 75 and older has received medical care or medication at or from a medical institution providing services covered by health insurance, etc. without obtaining confirmation that the insured is an insured through electronic certification confirmation, etc. and when the medical institution finds that the failure to obtain the confirmation was due to emergencies or other unavoidable reasons, the medical institution is to pay medical expenses in lieu of benefits for medical treatment, etc.; provided, however, that this does not apply during any period for which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article apply to the insured.
(3) The amount of medical expenses is determined by the Association of Medical Care Systems for the Elderly Aged 75 and older based on: (a) the amount calculated by deducting, from the amount calculated for the medical treatment (excluding dietary treatment and living support), the amount obtained by multiplying that amount by the applicable ratio specified in the items of Article 67, paragraph (1) in accordance with the categories of cases listed in the items of the same paragraph; and (b) the amount calculated by deducting, from the amount calculated for the dietary treatment or living support, the amount of standard co-payment for dietary treatment or standard co-payment for living support.
(4) With regard to the calculation of the amount of expenses referred to in the preceding paragraph, the provisions of Article 71, paragraph (1) apply mutatis mutandis if benefits for medical treatment are to be received, the provisions of Article 74, paragraph (2) apply mutatis mutandis if dietary treatment expenses for inpatients are to be received, the provisions of Article 75, paragraph (2) apply mutatis mutandis if living support expenses for inpatients are to be received, and the provisions of paragraph (2) of the preceding Article apply mutatis mutandis if medical expenses combined with treatment outside insurance coverage are to be received; provided, however, that the amount may not exceed the amount of expenses actually incurred in the medical treatment.
Division 2 Payment of Medical Expenses for Home-Nursing
(Medical Expenses for Home-Nursing)
Article 78  (1) If an insured receives home-nursing (meaning medical care or assistance for necessary medical care provided by a nurse or other person specified by Order of the Association of Medical Care Systems for the Elderly Aged 75 and older to an insured (limited to an Order of the Ministry of Health, Labour and Welfare whose degree of need for medical treatment is found by an attending physician to conform to standards specified by Order of the Order of the Ministry of Health, Labour and Welfare) who is in a state of continuous in-home medical treatment due to sickness or injury; hereinafter referred to as "designated home-nursing") from a designated home-nursing provider at a place of business that carries out home-nursing services (meaning home-nursing services as prescribed in Article 88, paragraph (1) of the Health Insurance Act) pertaining to the designation, the family hospital pays medical expenses for home-nursing to the insured for expenses required for the designated home-nursing; provided, however, that this does not apply during any period to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article apply to the insured.
(2) The medical expenses for home-nursing referred to in the preceding paragraph are to be paid only if the Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare.
(3) When an insured intends to receive designated home-nursing, the Order of the Ministry of Health, Labour and Welfare is to receive that designated home-nursing after being confirmed as an insured by an electronic certification confirmation, etc. from a designated home-nursing provider that it has selected, pursuant to the provisions of Order of the Ministry of Health, Labour, and Welfare.
(4) The amount of medical expenses for home-nursing is the amount calculated by deducting, from the amount calculated in accordance with the standards specified by the Minister of Health, Labour and Welfare in consideration of the average home-nursing expenses (meaning the average expenses required for designated home-nursing) for the relevant designated home-nursing, the amount obtained by multiplying the relevant amount by the applicable ratio specified in the items of Article 67, paragraph (1) in accordance with the categories of the cases listed in the items of the same paragraph (or, if any of the measures listed in the items of Article 69, paragraph (1) should be taken with respect to benefits for medical treatment, the amount calculated as if the relevant measures were taken).
(5) When the Minister of Health, Labour and Welfare intends to specify the standards set forth in the preceding paragraph, the Minister must hear the opinions of the Central Social Insurance Medical Council in advance.
(6) The provisions of Article 71, paragraph (2) apply mutatis mutandis to the authority of the Central Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.
(7) If a designated home-nursing provider requests payment of medical expenses for home-nursing, the Association of Medical Care Systems for the Elderly Aged 75 and older is to pay the expenses after conducting an examination in light of the standards specified by the Minister of Health, Labour and Welfare as set forth in paragraph (4) and the standards for business management of designated home-nursing as prescribed in paragraph (1) of the following Article (limited to the part regarding the treatment of designated home-nursing).
(8) The provisions of Article 70, paragraphs (4) through (7) and Article 74, paragraphs (5) through (7) apply mutatis mutandis to designated home-nursing received at or from a designated home-nursing provider and to the payment of medical expenses for home-nursing associated with the relevant service. In such a case, Cabinet Order provides for the necessary technical replacement of terms in connection with these provisions.
(9) The provisions of Article 68 apply mutatis mutandis to the payment of the amount calculated by deducting, from the amount of expenses calculated pursuant to the provisions of paragraph (4) in the case referred to in Article 74, paragraph (5) as applied mutatis mutandis pursuant to the preceding paragraph, the amount payable as medical expenses for home-nursing with respect to expenses incurred in the relevant designated home-nursing.
(10) Designated home-nursing is not to be included in any of the types of medical treatment listed in the items of Article 64, paragraph (1).
(11) Beyond what is provided for in the preceding paragraphs, necessary matters concerning the application of the calculation method specified by the Minister of Health, Labour and Welfare as set forth in paragraph (4) and a claim for medical expenses for home-nursing by a designated home-nursing provider are specified by Cabinet Order.
(Standards for Operations of Designated Home-Nursing Services)
Article 79  (1) Standards for operations of a designated home-nursing provider are provided by the Minister of Health, Labour and Welfare.
(2) A designated home-nursing provider must, in accordance with the standards concerning the management of a business of designated home-nursing prescribed in the preceding paragraph, provide appropriate designated home-nursing according to the mental and physical condition, etc., of an elderly person, and always endeavor to provide designated home-nursing from the viewpoint of the person that receives the designated home-nursing by implementing self-evaluation of the quality of the designated home-nursing provided and other measures.
(3) The Minister of Health, Labour and Welfare must hear the opinions of the Central Social Insurance Medical Council in advance, when the Minister intends to specify standards concerning the management of a designated home-nursing prescribed in paragraph (1) (limited to the part concerning the treatment of designated home-nursing).
(4) The provisions of Article 71, paragraph (2) apply mutatis mutandis to the authority of the Central Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.
(Guidance by the Minister of Health, Labour and Welfare or Prefectural Governors)
Article 80  A designated home-nursing provider and nurses and other employees at the office to which the designation pertains must receive guidance from the Minister of Health, Labour and Welfare or the prefectural governor with regard to designated home-nursing.
(Reports)
Article 81  (1) When the Minister of Health, Labour and Welfare or the prefectural governor finds it necessary in relation to the payment of medical expenses for home-nursing, the Minister or the governor may order a designated home-nursing provider, a person that was a designated home-nursing provider, or a person that was a nurse or other employee at the office relevant to the designation (hereinafter referred to as a "person that was a designated home-nursing provider, etc." in this paragraph) to make a report, submit or present books and documents, request the appearance of a designated home-nursing provider, a nurse or other employee at the office relevant to the designation, or a person that was a designated home-nursing provider, etc., or have their official question the persons concerned or inspect the books, documents, and other articles of the designated home-nursing provider at the office relevant to the designation.
(2) The provisions of Article 16-7, paragraph (2) apply mutatis mutandis to questions and inspections pursuant to the provisions of the preceding paragraph, and the provisions of paragraph (3) of the same Article apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding paragraph.
(3) If a prefectural governor finds it necessary for a designated home-nursing provider to be subject to a disposition under the provisions of Article 95 of the Health Insurance Act with regard to designated home-nursing under the provisions of this Act, the governor must notify the Minister of Health, Labour and Welfare to that effect by giving the reason therefor.
Division 3 Payment of Special Medical Expenses
Article 82  (1) If a insured that is delinquent in the payment of insurance premiums (excluding a insured that is eligible to receive payment of general medical expenses for illness under the Act on Assistance for Atomic Bomb Victims (Act No. 117 of 1994) and other medical care benefits specified by Order of the Ministry of Health, Labour and Welfare (referred to as "payment, etc. of general medical expenses for illness caused by atomic bombs" in paragraph (4)); hereinafter referred to as a "person delinquent in payment of insurance premiums" in this Article) does not pay the insurance premiums during the period from the due date for payment of the insurance premiums until the expiration of the period specified by Order of the Ministry of Health, Labour and Welfare, even though a municipality has made efforts to encourage payment of the insurance premiums, to secure opportunities for consultation pertaining to the payment of the insurance premiums, and to contribute to the payment of the insurance premiums specified by Order of the Ministry of Health, Labour and Welfare (referred to as "encouragement, etc. of payment of insurance premiums" in the following paragraph and Article 92, paragraphs (1) and (2)), and when the person delinquent in payment of insurance premiums has received medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing provider, the Association of Medical Care Systems for the Elderly Aged 75 and older pays to the person delinquent in payment of insurance premiums special medical expenses in lieu of benefits for medical treatment, or payment of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, or medical expenses for home-nursing (referred to as "benefits for medical treatment, etc." in the following paragraph, paragraph (4), and paragraph (5)), with regard to expenses required for the medical treatment or designated home-nursing, except when it is found that there are special circumstances specified by Cabinet Order.
(2) If a person delinquent in payment of insurance premiums fails to pay the insurance premiums even prior to the expiration of the period specified by Order of the Order of the Ministry of Health, Labour and Welfare as prescribed in the preceding paragraph, and the person delinquent in payment of insurance premiums receives medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing provider, the Association of Medical Care Systems for the Elderly Aged 75 and older may pay special medical expenses to the person delinquent in payment of insurance premiums for the expenses required for the medical treatment or designated home-nursing, in lieu of benefits for medical treatment, etc.; provided, however, that this does not apply when it is found that there are special circumstances specified by Cabinet Order referred to in the same paragraph.
(3) When paying special medical expenses pursuant to the provisions of paragraph (1) or the main clause of the preceding paragraph, the Association of Medical Care Systems for the Elderly Aged 75 and older is to notify a person delinquent in insurance premiums to the effect that special medical expenses will be paid if the person delinquent in insurance premiums receives medical treatment at or from a medical institution providing services covered by health insurance, or receives designated home-nursing at or from a designated home-nursing provider, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(4) If a person delinquent in payment of insurance premiums who is subject to the provisions of paragraph (1) or the main clause of paragraph (2) completes payment of the delinquent insurance premiums, or it is found that the amount of delinquent payment pertaining to the person has significantly decreased, or there are special circumstances specified by Cabinet Order, such as disasters, or if the relevant insured has become eligible for the payment, etc. of medical expenses for atomic bomb-related general diseases, and the insured that falls under these cases has received medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing provider, the Association of Medical Care Systems for the Elderly Aged 75 and older provides benefits for medical treatment, etc. to the relevant insured.
(5) A Association of Medical Care Systems for the Elderly Aged 75 and older, when providing benefits for medical treatment, etc. pursuant to the provisions of the preceding paragraph, pursuant to the provisions of Order of the Ministry of Health, Labour, and Welfare, is to, in advance, notify a Order of the Ministry of Health, Labour and Welfare that falls under the case prescribed in the same paragraph to the effect that it will provide benefits for medical treatment, etc. if the insured has received medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing provider in the case where the insured has received designated home-nursing.
(6) The provisions of Article 64 of the Health Insurance Act and Article 64, paragraph (3), Article 65, Article 66, Article 70, paragraph (2), Article 72, Article 74, paragraph (7) (including as applied mutatis mutandis pursuant to Article 78, paragraph (8)), Article 76, paragraph (2), Article 78, paragraph (3), Article 79, paragraph (2), Article 80, and the preceding Article of this Act apply mutatis mutandis to medical treatment or designated home-nursing pertaining to special medical expenses received at or from a medical institution providing services covered by health insurance, etc. or a designated home-nursing provider, and to the payment of special medical expenses incidental thereto. In this case, any necessary technical replacement of terms is specified by Cabinet Order.
(7) If a person delinquent in insurance premiums to whom the provisions of paragraph (1) or the main clause of paragraph (2) are applied would be subject to the provisions of Article 77, paragraph (1) if those provisions were not applied, the Association of Medical Care Systems for the Elderly Aged 75 and older may pay medical expenses to the person.
(8) If a person delinquent in payment of insurance premiums to whom the provisions of paragraph (1) or the main clause of paragraph (2) are applied receives medical care or medication at or from a medical institution providing services covered by health insurance without receiving confirmation that the person is an insured through electronic certification, etc., and the Association of Medical Care Systems for the Elderly Aged 75 and older finds that the person's failure to receive the confirmation is due to emergencies or other unavoidable reasons, the insurer is to pay medical expenses to the person.
(9) The provisions of Article 77, paragraphs (3) and (4) apply mutatis mutandis to the medical expenses pursuant to the provisions of the preceding two paragraphs. In this case, the term "if the person is to receive" in paragraph (4) of the same Article is deemed to be replaced with "if the person is eligible to receive".
Division 4 Payment of Transport Expenses
Article 83  (1) When an insured has been transferred to a hospital or clinic in order to receive medical treatment (including medical treatment covered by medical expenses combined with treatment outside insurance coverage and medical treatment covered by special medical expenses), the Association of Medical Care Systems for the Elderly Aged 75 and older pays, as transport expenses, an amount calculated pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare to the insured.
(2) The transport expenses referred to in the preceding paragraph are to be paid only if the Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
Subsection 3 Payment of High-Cost Medical Expenses and Sizable medical and nursing expenses
(High-Cost Medical Expenses)
Article 84  (1) When the amount of co-payment prescribed in Article 67 with respect to benefits for medical treatment or the amount calculated by deducting, from the amount of expenses incurred in medical treatment (excluding dietary treatment and living support; hereinafter the same applies in this Article), the amount paid as medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses with respect to the expenses incurred in the medical treatment, or the amount equivalent to the difference paid pursuant to the provisions of Article 57, paragraph (2) (referred to as the "amount of co-payment, etc." in paragraph (1) of the following Article) is extremely large, the Association of Medical Care Systems for the Elderly Aged 75 and older pays high-cost medical expenses to the insured that received the benefits for medical treatment, or the payment of the medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses.
(2) The requirements for payment and the amount of high-cost medical expenses and other necessary matters concerning the payment of high-cost medical expenses are specified by Cabinet Order by taking into consideration the impact of the burden of expenses necessary for medical treatment on household finances and the amount of expenses required for medical treatment.
(Sizable medical and nursing expenses)
Article 85  (1) When the sum of the amount of co-payment, etc. (when high-cost medical expenses set forth in paragraph (1) of the preceding Article are paid, the amount obtained by deducting the amount so paid) and the amount to be borne by a user of long-term care service as prescribed in Article 51, paragraph (1) of the Long-Term Care Insurance Act (when allowance for high-cost long-term care service set forth in the same paragraph is paid, the amount obtained by deducting the amount so paid) and the amount to be borne by a user of preventive long-term care service as prescribed in Article 61, paragraph (1) of the same Act (when High-Cost Long-Term Prevention Care Service Allowance set forth in the same paragraph is paid, the amount obtained by deducting the amount so paid) is extremely large, the Association of Medical Care Systems for the Elderly Aged 75 and older pays Sizable medical and nursing expenses to the insured that received benefits for medical treatment, or payment of medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses pertaining to the amount of co-payment, etc.
(2) The provisions of paragraph (2) of the preceding Article apply mutatis mutandis to the payment of a Sizable medical and nursing expenses.
Subsection 4 Other Late-Stage medical care benefit for the Elderly
Article 86  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older is to, pursuant to the provisions of Prefectural or Municipal Ordinances, pay funeral expenses or provide funeral rites benefits with regard to the death of an insured; provided, however, that if there are special reasons, the payment or benefits may not be made in whole or in part.
(2) In addition to the benefits set forth in the preceding paragraph, the Association of Medical Care Systems for the Elderly Aged 75 and older may pay injury and sickness allowance and provide other medical care benefit for the old-old pursuant to the provisions of the ordinances of the Association of Medical Care Systems for the Elderly Aged 75 and older.
Subsection 5 Restrictions on Late-Stage medical care benefit for the Elderly
Article 87  When an insured or a person who used to be an insured has suffered illness or injury intentionally or due to an intentional criminal act, benefits for medical treatment, or dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, or transport expenses pertaining to the illness or injury (hereinafter referred to as "benefits for medical treatment, etc." in this Subsection) are not paid.
Article 88  When a insured suffers illness or injury due to a conflict, state of drunkenness or extreme misconduct, benefits for medical treatment, etc. for such illness or injury may not be paid in whole or in part.
Article 89  If a person who is or was a insured is confined in a penal institution, workhouse, or any other facility equivalent thereto, no benefits for medical treatment, etc. are paid for the period during which the person is confined. insured.
Article 90  When a person who is or was a insured or insured fails to follow instructions concerning medical treatment without justifiable grounds, the Association of Medical Care Systems for the Elderly Aged 75 and older may refrain from providing part of the benefits, etc. for medical treatment.
Article 91  When a person who is or was a insured or insured or a person who receives an old-old medical care benefit fails to comply with an order pursuant to the provisions of Article 60 or refuses to answer questions or undergo a medical examination without justifiable grounds, the Association of Medical Care Systems for the Elderly Aged 75 and older may refrain from providing benefits for medical treatment, etc., in whole or in part.
Article 92  (1) If an medical care benefit that is eligible to receive an old-old insured is delinquent in payment of insurance premiums, and if the insurance premiums are not paid even after the recommendation of payment of insurance premiums, etc. by the municipality during the period from the due date for payment of the insurance premiums until the period specified by Order of the Ministry of Health, Labour and Welfare, the Association of Medical Care Systems for the Elderly Aged 75 and older, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, is to temporarily suspend the payment of the old-old medical care benefit in whole or in part, except in cases where it is found that there are special circumstances specified by Cabinet Order, such as a natural disaster, regarding the delinquency of the insurance premiums.
(2) Even in the case where the period specified by Order of the Order of the Ministry of Health, Labour and Welfare as prescribed in the preceding paragraph has not elapsed, if a medical care benefit eligible to receive an old-old insured is still delinquent in payment of insurance premiums even after the recommendation, etc. of payment of insurance premiums by a municipality, the Association of Medical Care Systems for the Elderly Aged 75 and older, pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare, may temporarily suspend payment of the old-old medical care benefit in whole or in part, except in the case where it is found that there are special circumstances specified by Cabinet Order, such as a natural disaster, regarding the delinquency of the insurance premiums.
(3) If an insured to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) are applied and for which the payment of the old-old medical care benefit has been temporarily suspended in whole or in part pursuant to the provisions of the preceding two paragraphs still does not pay the delinquent insurance premiums, the Association of Medical Care Systems for the Elderly Aged 75 and older may, pursuant to the provisions of the Order of the Ministry of Health, Labour and Welfare, deduct the amount of the insurance premiums that the insured is delinquent from the amount of the old-old medical care benefit pertaining to the temporary suspension, by giving notice to the insured in advance.
Section 4 Expenses
Subsection 1 Bearing of Expenses
(Expenses Borne by the State)
Article 93  (1) Pursuant to the provisions of Cabinet Order, the national government is to bear the Association of Medical Care Systems for the Elderly Aged 75 and older the amount equivalent to three twelfth of the sum of the amount calculated by deducting, from the amount of expenses incurred in providing benefits for medical treatment pertaining to insured, the amount equivalent to the co-payment pertaining to the relevant benefits, and the sum of the amount of expenses incurred in paying dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, transport expenses, high-cost medical expenses and Sizable medical and nursing expenses (hereinafter referred to as the "amount of expenses incurred in providing benefits for medical treatment, etc."), the amount of expenses incurred in providing benefits for medical treatment, etc. pertaining to persons who fall under the cases set forth in Article 67, paragraph (1), item (iii) (hereinafter referred to as the "amount of specified expenses") (the amount thus calculated is referred to as the "amount subject to sharing" in item (i) and Article 100, paragraph (1) in the following paragraph), and the amount calculated by deducting, from the amount of contributions to ensure medical care in the early stage of an outbreak, the amount obtained by multiplying the amount of the relevant contributions to ensure medical care in the early stage of an outbreak by the ratio of the amount of specified expenses to the amount of expenses incurred in providing benefits for medical treatment, etc. (referred to as the "amount of contributions to ensure specified medical care in the early stage of an outbreak" in Article 100, paragraph (1)) (the amount thus calculated is referred to as the "amount Article 100, paragraph (1)
(2) Beyond what is set forth in the preceding paragraph, the national government, pursuant to the provisions of Cabinet Order, in order to stabilize the finances of Old-Old Healthcare, is to bear an amount equivalent to one fourth of the amount obtained by multiplying the total amount of expenses required for benefits related to high-cost medical care, which is not less than the amount calculated pursuant to the provisions of Cabinet Order as having a significant influence on the finances of Old-Old Healthcare due to the occurrence of benefits related to high-cost medical care, by the sum of the following rates (referred to as the "Amount Subject to high medical care cost Burden" in Article 96, paragraph (2)), in consideration of the ratio of benefits related to high-cost medical care to the amount of expenses required for benefits related to all medical care pertaining to the insured (referred to as the "Amount Subject to National Health Insurance Burden" in Article 96 Association of Medical Care Systems for the Elderly Aged 75 and older:
(i) the rate obtained by dividing the amount equivalent to one twelfth of the Amount Subject to Sharing by the amount of expenses required for Benefits for Medical Treatment, etc.;
(ii) the co-payment rate for the old-old in Article 100, paragraph (1).
(3) Beyond what is provided for in the preceding two paragraphs, pursuant to the provisions of Cabinet Order, the national government is to grant two-thirds of the total estimated amount of special burden adjustment, etc. for the relevant fiscal year to the Payment Fund each fiscal year; provided, however, that if the total estimated amount of special burden adjustment, etc. for the fiscal year before the previous fiscal year exceeds the total amount of special burden adjustment, etc. for the same fiscal year, the national government is to grant two-thirds of the amount obtained by subtracting the excess amount from the total estimated amount of special burden adjustment, etc. for the relevant fiscal year, and if the total estimated amount of special burden adjustment, etc. for the fiscal year before the previous fiscal year is less than the total amount of special burden adjustment, etc. for the same fiscal year, the national government is to grant two-thirds of the amount obtained by adding the less amount to the total estimated amount of special burden adjustment, etc. for the relevant fiscal year.
(Reduction of Treasury Share)
Article 94  (1) If a Association of Medical Care Systems for the Elderly Aged 75 and older unjustly fails to secure the revenue that it should have secured, the national government may reduce the amount to be borne by the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the preceding Article, pursuant to the provisions of Cabinet Order.
(2) The amount to be reduced pursuant to the provisions of the preceding paragraph may not exceed the amount which was unjustly not secured.
(Adjustment Grants)
Article 95  (1) The national government provides adjustment grants to a Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of a Cabinet Order in order to adjust the finances of medical care for the elderly.
(2) The total amount of adjusting subsidies pursuant to the provisions of the preceding paragraph is an amount equivalent to one twelfth of the total estimated amount of the total amount subject to sharing.
(Expenses Borne by Prefectures)
Article 96  (1) A prefecture, pursuant to the provisions of Cabinet Order, bears an amount equivalent to one twelfth of the total amount subject to sharing by a Association of Medical Care Systems for the Elderly Aged 75 and older.
(2) Beyond what is set forth in the preceding paragraph, a prefecture is to bear an amount equivalent to one fourth of the amount subject to high medical care cost contribution to the Association of Medical Care Systems for the Elderly Aged 75 and older, pursuant to the provisions of Cabinet Order.
(Reduction of Prefecture's Contribution)
Article 97  (1) If a Association of Medical Care Systems for the Elderly Aged 75 and older unjustly fails to secure the revenue it should have secured and the national government reduces the amount to be borne pursuant to the provisions of Article 94, the prefecture may reduce the amount to be borne by the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the preceding Article, pursuant to the provisions of Cabinet Order.
(2) The amount to be reduced pursuant to the provisions of the preceding paragraph may not exceed the amount which was unjustly not secured.
(Burden on the General Account of a Municipality)
Article 98  A Municipality, pursuant to the provisions of a Cabinet Order, is to bear an amount equivalent to one twelfth of the Total Amount Subject to Sharing with a Association of Medical Care Systems for the Elderly Aged 75 and older in its general account.
(Transfer to the Special Account of a Municipality)
Article 99  (1) A Municipality, pursuant to the provisions of a Cabinet Order, must transfer from the general account to the special account for medical care for the elderly of the Municipality the amount calculated, pursuant to the provisions of a Cabinet Order, based on the total amount of insurance premiums pertaining to the insured reduced based on the reduced assessment of insurance premiums for persons with small income pursuant to the provisions of the Ordinances of the Association of Medical Care Systems for the Elderly Aged 75 and older, by taking into consideration the financial status of medical care for the elderly and other circumstances.
(2) A Municipality, with regard to a mutual aid association who was a dependent pursuant to the provisions of the Health Insurance Act, the Mariners Insurance Act, the National Public Officers' local public employee Act (including as applied mutatis mutandis pursuant to other Acts), or the mutual aid association, etc. Insurance Act as of the day preceding the day on which the insured came to fall under any of the items of Article 52, must transfer the amount calculated pursuant to the provisions of a Cabinet Order, based on the total amount of insurance premiums reduced based on the reduced assessment of insurance premiums carried out pursuant to the provisions of a Municipal Ordinance and in consideration of the financial status of Old-Old Healthcare and other circumstances, from the general account to the special account for Old-Old Healthcare of the Municipality, limited to the period until the month in which two years have elapsed from the month including the day on which the Insured Person came to fall under any of the items of the same Article.
(3) A prefecture, pursuant to the provisions of Cabinet Order, bears an amount equivalent to three quarters of the amount to be transferred pursuant to the provisions of the preceding two paragraphs.
(Old-Old Subsidy)
Article 100  (1) Among the expenses to be borne by the Association of Medical Care Systems for the Elderly Aged 75 and older under its special account for medical care for the elderly aged 75 or older, the amount obtained by adding the sum of the amount obtained by multiplying the amount subject to payment by the rate obtained by subtracting the contribution rate for the elderly aged 75 or older and 50 percent from one, and the amount obtained by multiplying the amount of specified expenses by the rate obtained by subtracting the contribution rate for the elderly aged 75 or older from one (hereinafter referred to as the "amount subject to insurance payment" in this Section), and the sum of the amount obtained by multiplying the amount of contributions subject to payment by the rate obtained by subtracting the contribution rate for the elderly aged 75 or older and 50 percent from one, and the amount obtained by multiplying the amount of contributions to ensure specific early fashion medical care by the rate obtained by subtracting the contribution rate for the elderly aged 75 or older from one (referred to as the "total amount subject to insurance payment" in Article 121, paragraph (1)) is to be covered by the grant for the elderly aged 75 or older granted by the Payment Fund to the Association of Medical Care Systems for the Elderly Aged 75 and older, pursuant to the provisions of Cabinet Order.
(2) The contribution rate for the old-old set forth in the preceding paragraph is specified by Cabinet Order every two years based on the rate obtained by multiplying the number set forth in item (i) by the rate set forth in item (ii) and then dividing the product by the number set forth in item (iii):
(i) the number obtained by adding, to one half, a rate equivalent to one half of the ratio of the amount of specified expenses to the amount of expenses required for benefits for medical treatment, etc. in the relevant fiscal year.
(ii) The rate obtained by multiplying 11.72 percent by the rate obtained by dividing the prospective total number of insured pertaining to all Association of Medical Care Systems for the Elderly Aged 75 and older in the relevant fiscal year by the total number of insured pertaining to all Association of Medical Care Systems for the Elderly Aged 75 and older in fiscal year 2022. 200
(iii) the number arrived at when the rate set forth in the preceding item is added to the rate arrived at when the rate set forth in (a) is multiplied by the rate set forth in (b):
(a) the rate obtained by dividing the amount subject to insurance payment in fiscal year 2022 by the amount of expenses required for benefits for medical treatment, etc. in the same fiscal year;
(b) the rate arrived at when the prospective total number of participants for all insurers in the relevant fiscal year is divided by the total number of participants for all insurers in fiscal 2022.
(3) Medical Care Assistance for the Elderly Aged 75 and over collected by the Payment Fund pursuant to the provisions of Article 118, paragraph (1) is to be allocated to the Old-Old Subsidy referred to in paragraph (1).
(Reduction of Old-Old Subsidy)
Article 101  (1) If a Association of Medical Care Systems for the Elderly Aged 75 and older unjustly fails to secure the revenue that it should have secured or unjustly incurs expenses that it should not incur, the Minister of Health, Labour and Welfare may order the Payment Fund to reduce the amount of the grant for the old-old set forth in paragraph (1) of the preceding Article that is granted to the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the same paragraph, pursuant to the provisions of Cabinet Order. Association of Medical Care Systems for the Elderly Aged 75 and older.
(2) The amount to be reduced pursuant to the provisions of the preceding paragraph may not exceed the amount which has unjustly failed to be secured or the amount which has unjustly been expended.
(Subsidies from the State)
Article 102  In addition to what is provided for in Article 93, Articles 95 and 116, paragraph (6), the national government may subsidize part of the expenses required for medical care for elderly people within the scope of the budget.
(Subsidies and Loans from the Prefectural, Municipal and Association of Medical Care Systems for the Elderly Aged 75 and older)
Article 103  Beyond what is provided for in Article 96, Article 98, Articles 99 and 116, paragraph (5), a prefecture, municipality, and Association of Medical Care Systems for the Elderly Aged 75 and older may provide subsidies or loans for expenses required for medical care for elderly persons.
(Insurance Premiums)
Article 104  (1) A Municipality must collect insurance premiums to be allocated for expenses required for Old-Old Healthcare (including expenses required for payment of Fiscal Stability Fund contributions, contributions and childbirth and childcare support money under the provisions of Article 117, paragraph (2), and contributions, etc. to ensure medical care in the early stage of an outbreak under the provisions of Act on the Prevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases (referred to as "Contributions, etc. to ensure medical care in the early stage of an outbreak" in paragraph (3) and Article 116, paragraph (2))).
(2) The insurance premiums set forth in the preceding paragraph are imposed by a Association of Medical Care Systems for the Elderly Aged 75 and older on a insured based on the amount of insurance premiums calculated based on the insurance premiums rate calculated pursuant to the provisions of Prefectural or Municipal Ordinance of the Association of Medical Care Systems for the Elderly Aged 75 and older in accordance with the requirement that the insurance premiums rate is the same for all areas of the Association of Medical Care Systems for the Elderly Aged 75 and older and other requirements specified by Cabinet Order; provided, however, that with regard to the insurance premiums of a insured which is domiciled in an isolated island or any other area within the area of the Association of Medical Care Systems for the Elderly Aged 75 and older where it is extremely difficult to ensure medical care and which falls under the requirements specified by the Minister of Health, Labour and Welfare, the insurance premiums may be imposed based on the amount of insurance premiums calculated based on the insurance premiums rate separately calculated pursuant to the provisions of Prefectural or Municipal Ordinance of the Association of Medical Care Systems for the Elderly Aged 75 and older in accordance with the requirements specified by Cabinet Order.
(3) The insurance premiums rate referred to in the preceding paragraph must be able to maintain a balanced budget in general throughout two years in light of the estimated amount of expenses required for benefits for medical treatment, etc., the estimated amount of expenses required for payment of the Fiscal Stability Fund contributions, contributions and childbirth and childcare support money pursuant to the provisions of Article 117, paragraph (2), and contributions for securing medical care in the early stage of an epidemic, etc., the estimated amount of expenses required for redemption of borrowings from the prefecture pursuant to the provisions of Article 116, paragraph (1), item (ii), the estimated amount of expenses required for health services for the elderly provided for in Article 125, paragraph (1) and for the services provided for in paragraph (5) of the same Article, the status of distribution of income in insured and its prospects, the national treasury burden, and the amount of grants, etc. for the old-old in Article 100, paragraph (1).
(Payment of Insurance Premiums)
Article 105  A Municipality is to pay to a Association of Medical Care Systems for the Elderly Aged 75 and older the amount to be transferred pursuant to the provisions of Article 99, paragraphs (1) and (2) and insurance premiums and any other money to be collected pursuant to the provisions of this Chapter (limited to those collected by the Municipality) pursuant to the provisions of the constitution of the Association of Medical Care Systems for the Elderly Aged 75 and older, in order to cover the expenses required for the Old-Old Healthcare provided by the Association of Medical Care Systems for the Elderly Aged 75 and older.
(Assessment Date)
Article 106  The assessment date for insurance premiums is the first day of the relevant fiscal year.
(Method of Collecting Insurance Premiums)
Article 107  (1) The collection of insurance premiums of Article 104 by a Municipality must be made by the method of general collection (meaning that a Municipality collects insurance premiums by giving a notice of payment to the insured on which the insurance premiums are imposed, or to the head of the household to which the relevant insured belongs, or to the spouses of the relevant insured (including a person who has not submitted a notification of marriage but is in a de facto marital relationship with the person; the same applies hereinafter) pursuant to the provisions of Article 231 of the Local Autonomy Act (Act No. 67 of 1947); the same applies hereinafter); the same applies hereinafter), except in the case of special collection (meaning that a Municipality has a person who pays an Old Age, etc. pension benefit (hereinafter referred to as a "Pension pension benefit") collect insurance premiums from an Old Age, etc. Insurer (excluding a person specified by Cabinet Order) and pay the insurance premiums to be collected; the same applies hereinafter). insured.
(2) The Old Age, etc. pension benefit set forth in the preceding paragraph means the Old Age Basic Pension under the National Pension Act (Act No. 141 of 1959) and other pension benefits under the same Act or the Employee's Pension Insurance Act (Act No. 115 of 1954) for which the grounds for payment are old age, disability, or death, which are specified by Cabinet Order, and pension benefits similar to these pension benefits for which the grounds for payment are old age, retirement, disability, or death, which are specified by Cabinet Order.
(Obligation to Pay Insurance Premiums Pertaining to General Collection)
Article 108  (1) Insured must pay the insurance premiums when a Municipality intends to collect the person's insurance premiums by the method of general collection.
(2) When a Municipality intends to collect insurance premiums of a insured belonging to a household by the method of general collection, the Householder is liable to jointly and severally pay the insurance premiums.
(3) If a Municipality intends to collect insurance premiums of the other party that is a insured by the method of general collection, one of the spouses is liable to pay the insurance premiums jointly and severally.
(Due Date of Insurance Premiums Pertaining to General Collection)
Article 109  The due date of payment of insurance premiums collected by the method of general collection is specified by Municipal Ordinance.
(Mutatis Mutandis Application of Long-Term Care Insurance Act)
Article 110  The provisions of Articles 134 through 141-2, Long-Term Care Insurance Act apply mutatis mutandis to the special collection of insurance premiums conducted pursuant to the provisions of Article 107. In this case, the necessary technical replacement of terms is specified by Cabinet Order.
(Reduction and Exemption of Insurance Premiums)
Article 111  The Association of Medical Care Systems for the Elderly Aged 75 and older may, pursuant to the provisions of Prefectural Ordinances, reduce or exempt insurance premiums or suspend the collection thereof for persons with special reasons.
(Mutatis Mutandis Application of the Local Tax Act)
Article 112  The provisions of Article 9, Article 13-2, Article 20, Article 20-2, and Article 20-4 of the Local Tax Act (Act No. 226 of 1950) apply mutatis mutandis to insurance premiums and any other money to be collected pursuant to the provisions of this Chapter (limited to those to be collected by municipalities and Association of Medical Care Systems for the Elderly Aged 75 and older).
(disposition to collect arrears)
Article 113  Insurance premiums collected by a municipality, co-payment for which collection has been suspended and which is collected by a Association of Medical Care Systems for the Elderly Aged 75 and older, and any other money to be collected pursuant to the provisions of this Chapter are revenues specified by laws as prescribed in Article 231-3, paragraph (3) of the Local Autonomy Act.
(Entrustment of Collection of Insurance Premiums)
Article 114  A Municipality may entrust the affairs of the collection of insurance premiums collected by the method of general collection to a person designated pursuant to the provisions of Article 243-2, paragraph (1) of the Local Autonomy Act, only when it is found that the entrustment will contribute to the assurance of revenue and the promotion of the benefits of the insured.
(Delegation to Ordinance)
Article 115  (1) Beyond what is provided for in this Subsection, the amount of insurance premiums to be imposed and other particulars concerning the imposition of insurance premiums are prescribed by Ordinance of the Association of Medical Care Systems for the Elderly Aged 75 and older in accordance with the standards specified by Cabinet Order.
(2) Beyond what is provided for in this Subsection, the notification of the amount of insurance premiums and other matters concerning the collection of insurance premiums (excluding those concerning special collection) are specified by Municipal Ordinance in accordance with the standards specified by Cabinet Order, and necessary matters concerning special collection are specified by Cabinet Order or Municipal Ordinance in accordance with the standards specified by Cabinet Order.
Subsection 2 Fiscal Stability Funds
Article 116  (1) A prefecture, in order to contribute to the financial stability of medical care for the elderly, is to establish a financial stability fund to cover the expenses necessary for the following projects:
(i) a project to provide a Association of Medical Care Systems for the Elderly Aged 75 and older whose actual amount of insurance premiums received is expected to fall short of the estimated amount of insurance premiums received and whose amount of revenue subject to a fund project is expected to fall short of the amount of expenses subject to a fund project with an amount calculated pursuant to the provisions of Cabinet Order based on an amount equivalent to half of the amount listed in (a) below (if the amount listed in (a) below exceeds the amount listed in (b) below, the amount listed in (b) below) by taking into consideration the status of receipt of insurance premiums, etc. in the municipality that organizes the Association of Medical Care Systems for the Elderly Aged 75 and older, pursuant to the provisions of Cabinet Order:
(a) the amount of insurance premiums actually received that is expected to be less than the amount of insurance premiums scheduled to be received;
(b) the amount by which the Amount of Revenue Covered by the Fund Project is expected to be short of the Amount of Cost Covered by the Fund Project;
(ii) a project to provide a Association of Medical Care Systems for the Elderly Aged 75 and older whose total of the Revenue Subject to a Fund Project and the Amount Delivered by a Fund Project is expected to fall short of the Amount of Expenses Subject to a Fund Project with a loan, pursuant to the provisions of Cabinet Order, in an amount not exceeding the amount calculated pursuant to the provisions of Cabinet Order, based on the expected shortfall, by taking into consideration the status of collection of insurance premiums, etc. in the Municipality that organizes the Association of Medical Care Systems for the Elderly Aged 75 and older.
(2) Among the terms used in the preceding paragraph, the meanings of those set forth in the following items are as prescribed respectively in those items:
(i) the estimated amount of insurance premiums received: the amount calculated pursuant to the provisions of Cabinet Order as the amount to be allocated to the amount of expenses required for benefits for medical treatment, etc., the amount of expenses required for payment of the Fiscal Stability Fund contributions, the contributions pursuant to the provisions of paragraph (2) of the following Article, childbirth and childcare support benefits, and contributions for securing medical care in the early stage of an epidemic, etc., and the amount of expenses required for reimbursement of borrowings from the prefecture pursuant to the provisions of item (ii) of the preceding paragraph (hereinafter referred to as "borrowings under fund projects" in this paragraph) out of the total amount of insurance premiums that are expected to be received by the Municipality which organizes the Association of Medical Care Systems for the Elderly Aged 75 and older during the Specified Period (meaning the period of every two fiscal years from the fiscal year 2008 as the first year; hereinafter the same applies in this paragraph) in the Municipality which organizes the Association of Medical Care Systems for the Elderly Aged 75 and older;
(ii) the actual amount of insurance premiums received: the sum of the total amount of insurance premiums received by the Municipality incorporating the Association of Medical Care Systems for the Elderly Aged 75 and older during the Specified Period, which is calculated by deducting, from the amount of expenses incurred in providing benefits for medical treatment, the amount of co-payment relating to the relevant benefits; and the sum of the amount of expenses incurred in paying dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, transport expenses, high-cost medical expenses, and Sizable medical and nursing expenses (hereinafter referred to as the "amount of expenses incurred in providing benefits for medical treatment, etc." in this paragraph); the amount of expenses incurred in paying Fiscal Stability Fund contributions, contributions pursuant to the provisions of paragraph (2) of the following Article, childbirth and childcare support benefits, and contributions, etc. for securing medical care in the early stage of an epidemic; and the amount calculated pursuant to the provisions of a Cabinet Order as the amount to be allocated to the amount of expenses incurred in the redemption of Borrowings;
(iii) the amount of revenue subject to a fund project: the amount calculated pursuant to the provisions of Cabinet Order as the amount to be allocated to the amount of expenses required for benefits for medical treatment, etc., the amount of expenses required for payment of the Fiscal Stability Fund contributions, contributions pursuant to the provisions of paragraph (2) of the following Article and childbirth and childcare support benefits, and contributions, etc. for ensuring medical care in the early stage of an epidemic, and the amount of expenses required for reimbursement of borrowings under a fund project, out of the sum of the amount received during a specified period in a special account for medical care for the elderly covered by a Association of Medical Care Systems for the Elderly Aged 75 and older (excluding the amount of grants under a fund project and the amount of borrowings under a fund project set forth in item (v));
(iv) the Amount of Expenses Subject to Fund Projects: the amount calculated pursuant to the provisions of Cabinet Order as the sum of the amount of expenses required for benefits for medical treatment, etc., the amount of expenses required for payment of Fiscal Stability Fund contributions, contributions pursuant to the provisions of paragraph (2) of the following Article and childbirth and childcare support benefits, and Contributions for Ensuring Medical Care in the Early Stage of Epidemics, etc., and the amount of expenses required for redemption of Fund Project Borrowings during the Specified Period at the Association of Medical Care Systems for the Elderly Aged 75 and older;
(v) the amount of grants for fund business: the amount that a Association of Medical Care Systems for the Elderly Aged 75 and older has received pursuant to the provisions of item (i) of the preceding paragraph during the specified period.
(3) A prefecture, pursuant to the provisions of Cabinet Order, is to collect Fiscal Stability Fund contributions from the Association of Medical Care Systems for the Elderly Aged 75 and older in order to allocate them to the Fiscal Stability Fund.
(4) The Association of Medical Care Systems for the Elderly Aged 75 and older is obliged to pay the Fiscal Stability Fund contribution pursuant to the provisions of the preceding paragraph.
(5) A prefecture, pursuant to the provisions of Cabinet Order, must transfer an amount equivalent to three times the total amount of Fiscal Stability Fund contributions collected from the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of paragraph (3) to the Fiscal Stability Fund.
(6) Pursuant to the provisions of Cabinet Order, the national government bears an amount equivalent to one third of the amount transferred by a prefecture pursuant to the provisions of the preceding paragraph.
(7) All revenues arising from the Fiscal Stability Fund must be appropriated to the Fiscal Stability Fund.
Subsection 3 Special high medical care cost Joint Enterprise
Article 117  (1) A designated corporation, pursuant to the provisions of Cabinet Order, in order to mitigate the impact of the occurrence of benefits related to extremely expensive medical care on the finances of medical care for the elderly, is to implement a project to provide Association of Medical Care Systems for the Elderly Aged 75 and older with grants related to benefits related to extremely expensive medical care pertaining to insured (hereinafter referred to as a "special joint high medical care cost project").
(2) Designated Corporations, pursuant to the provisions of Cabinet Order, collect contributions from the Association of Medical Care Systems for the Elderly Aged 75 and older to cover the expenses required for the Special high medical care cost Joint Enterprise.
(3) A Association of Medical Care Systems for the Elderly Aged 75 and older is liable to pay contributions pursuant to the provisions of the preceding paragraph.
Subsection 4 Medical Care Assistance for the Elderly Aged 75 and over by Insurers
(Collection and Payment Obligations of Medical Care Assistance for the Elderly Aged 75 and over Monies)
Article 118  (1) The Payment Fund collects Medical Care Assistance for the Elderly Aged 75 and over and contributions for office expenses related to old-old age (hereinafter referred to as "Medical Care Assistance for the Elderly Aged 75 and over, etc.") from Insurers (or prefectures in the case of national health insurance; hereinafter the same applies in this Section) each fiscal year in order to cover the expenses required for the services listed in Article 139, paragraph (1), item (ii).
(2) Insurers are liable to pay Medical Care Assistance for the Elderly Aged 75 and over money, etc.
(Amount of Medical Care Assistance for the Elderly Aged 75 and over)
Article 119  (1) The amount of Medical Care Assistance for the Elderly Aged 75 and over collected from each of the Insurers pursuant to the provisions of paragraph (1) of the preceding Article is the amount of estimated Medical Care Assistance for the Elderly Aged 75 and over for the relevant fiscal year; provided, however, that if the amount of estimated Medical Care Assistance for the Elderly Aged 75 and over for the fiscal year before the previous fiscal year exceeds the amount of final Medical Care Assistance for the Elderly Aged 75 and over for the same fiscal year, the amount is to be the amount obtained by subtracting the sum of the excess amount and the Old-Old Adjustment Amount pertaining to the excess amount from the amount of estimated Medical Care Assistance for the Elderly Aged 75 and over for the relevant fiscal year, and if the amount of estimated Medical Care Assistance for the Elderly Aged 75 and over for the fiscal year before the previous fiscal year is less than the amount of final for the same fiscal year, the amount is to be the amount obtained by adding the sum of the amount of estimated for the relevant fiscal year, the amount of the shortfall amount, and the Old-Old Adjustment Amount pertaining to the shortfall amount. Medical Care Assistance for the Elderly Aged 75 and over Medical Care Assistance for the Elderly Aged 75 and over.
(2) The amount of adjustment for late-stage elderly as prescribed in the preceding paragraph is the amount calculated for each of the Insurers pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare by taking into consideration the interest arising from any excess or deficiency between the estimated amount of Medical Care Assistance for the Elderly Aged 75 and over and the amount of final Medical Care Assistance for the Elderly Aged 75 and over pertaining to all Insurers in the fiscal year before the previous fiscal year and any other circumstances.
(Estimated Medical Care Assistance for the Elderly Aged 75 and over)
Article 120  (1) The estimated amount of Medical Care Assistance for the Elderly Aged 75 and over referred to in paragraph (1) of the preceding Article is the amount specified in the relevant of the following items for the category of insurers set forth in that item:
(i) insurers of employee insurance, etc.: the amount obtained by first dividing the total prospective amount of insurance proceeds payable by all Insurers in the relevant fiscal year by the total prospective number of subscribers for all Insurers in the same fiscal year calculated as specified by Order of the Ministry of Health, Labour and Welfare, then multiplying the product by the prospective number of subscribers for all Insurers of employee insurance, etc. in the same fiscal year calculated as specified by Order of the Ministry of Health, Labour and Welfare, then multiplying the product by the rate obtained by dividing the amount set forth in (a) by the amount set forth in (b) for the same fiscal year and the estimated Medical Care Assistance for the Elderly Aged 75 and over adjustment rate for the same fiscal year: Association of Medical Care Systems for the Elderly Aged 75 and older:
(a) the estimated amount of the Total Amount of Standard Fees pertaining to the Insurer of employee insurance, etc.;
(b) the sum of the estimated amounts of the total amount of standardized remunerations pertaining to all Insurers of employee insurance, etc.;
(ii) insurers other than insurers covered by employee insurance, etc.: the amount obtained by first dividing the total prospective amount of insurance proceeds payable by all insurers in the relevant fiscal year by the total prospective number of subscribers for all insurers in the relevant fiscal year calculated as prescribed by Order of the Ministry of Health, Labour and Welfare, multiplying the result by the prospective number of subscribers for the relevant Association of Medical Care Systems for the Elderly Aged 75 and older in the relevant fiscal year calculated as prescribed by Order of the Ministry of Health, Labour and Welfare, and then multiplying the product by the estimated Medical Care Assistance for the Elderly Aged 75 and over adjustment rate.
(2) The estimated Medical Care Assistance for the Elderly Aged 75 and over adjustment rate referred to in the items of the preceding paragraph is calculated pursuant to the provisions of Cabinet Order within the range of 90 percent to 110 percent by taking into consideration the degree of achievement of the particulars set forth in Article 18, paragraph (2), item (ii) and Article 19, paragraph (2), item (ii), the expected number of subscribers pertaining to the insurers, and other factors.
(Final Medical Care Assistance for the Elderly Aged 75 and over)
Article 121  (1) The amount of final Medical Care Assistance for the Elderly Aged 75 and over for Article 119, paragraph (1) is the amount specified in each of the following items in accordance with the category of insurers listed in the relevant item:
(i) association of Medical Care Systems for the Elderly Aged 75 and older of employee insurance, etc.: the amount obtained by first dividing the total amount of all insurers' total amount subject to insurance payment in the fiscal year before the previous fiscal year by the total number of subscribers for all insurers in the same fiscal year, calculated as specified by Order of Order of the Ministry of Health, Labour and Welfare, then multiplying the product by the number of subscribers for all insurers of employee insurance, etc. in the same fiscal year, calculated as specified by Order of Order of the Ministry of Health, Labour and Welfare, then multiplying the product by the rate obtained by dividing the amount set forth in (a) by the amount set forth in (b) for the same fiscal year, and then multiplying the product by the fixed Medical Care Assistance for the Elderly Aged 75 and over adjustment rate:
(a) the total amount of standard compensation pertaining to the Insurer of employee insurance, etc.;
(b) the sum of the Total Amount of Standard Fees pertaining to all Insurers of employee insurance, etc.;
(ii) insurers other than insurers covered by employee insurance, etc.: the amount arrived at when the total amount subject to insurance payment for all insurers in the fiscal year before the relevant fiscal year is divided by the total number of subscribers for all insurers in that fiscal year calculated as prescribed by Order of the Ministry of Health, Labour and Welfare, the amount arrived at when the product is multiplied by the number of subscribers for that Association of Medical Care Systems for the Elderly Aged 75 and older in that fiscal year calculated as prescribed by Order of the Ministry of Health, Labour and Welfare, and the product is multiplied by the fixed Medical Care Assistance for the Elderly Aged 75 and over adjustment rate.
(2) The fixed adjustment rate for the Medical Care Assistance for the Elderly Aged 75 and over referred to in the items of the preceding paragraph is calculated pursuant to the provisions of Cabinet Order within the range of 90 percent to 110 percent, in consideration of the degree of achievement of the particulars set forth in Article 18, paragraph (2), item (ii) and Article 19, paragraph (2), item (ii), the number of subscribers pertaining to insurers, and other factors.
(Amount of Contributions for Office Expenses Related to Old-Old Age)
Article 122  The amount of contributions for administrative expenses related to the old-old to be collected from each of the Insurers pursuant to the provisions of Article 118, paragraph (1) is the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, based on the estimated amount of expenses required for the processing of affairs concerning the Payment Fund services listed in Article 139, paragraph (1), item (ii) in the relevant fiscal year, in accordance with the estimated number of subscribers pertaining to each of the Insurers, as specified by Order of the Ministry of Health, Labour and Welfare.
(Notification)
Article 123  (1) Pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, the Association of Medical Care Systems for the Elderly Aged 75 and older must notify the Payment Fund of the amount subject to insurance payment in each fiscal year and other matters specified by Order of the Ministry of Health, Labour and Welfare.
(2) The Association of Medical Care Systems for the Elderly Aged 75 and older may delegate the affairs concerning the notification under the preceding paragraph to the NHI Federations.
(Application Mutatis Mutandis)
Article 124  The provisions of Article 41 and Articles 43 through 46 apply mutatis mutandis to Medical Care Assistance for the Elderly Aged 75 and over money, etc.
Subsection 5 Childbirth and Childcare Support Benefits of a Association of Medical Care Systems for the Elderly Aged 75 and older
(Collection and Payment Obligation of Childbirth and Childcare Support Benefits)
Article 124-2  (1) The Payment Fund collects childbirth and childcare support grants from the Association of Medical Care Systems for the Elderly Aged 75 and older each fiscal year to cover the expenses required for the services listed in Article 139, paragraph (1), item (iii).
(2) A Association of Medical Care Systems for the Elderly Aged 75 and older is liable to pay childbirth and childcare support benefits.
(Amount of Childbirth and Childcare Support Benefits)
Article 124-3  (1) The amount of childbirth and childcare support collected from each Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of paragraph (1) of the preceding Article is to be the amount obtained by multiplying the amount calculated pursuant to the provisions of paragraph (1) and Article 124-7, paragraph (1) based on the total amount of expenses required for payment of lump-sum allowance for childbirth and childcare, Family lump-sum payment of childbirth and childcare, Parturition Expenses, and family Parturition Expenses pursuant to the provisions of the Medical Insurance Acts (referred to as "expenses required for payment of lump-sum allowance for childbirth and childcare, etc." in Order of the Ministry of Health, Labour and Welfare of the following Article) by the childbirth and childcare support rate and the ratio of the number of insured pertaining to the relevant Association of Medical Care Systems for the Elderly Aged 75 and older to the total number of insured pertaining to all hospitals. Association of Medical Care Systems for the Elderly Aged 75 and older.
(2) The childbirth and childcare support rate referred to in the preceding paragraph for fiscal year 2024 and fiscal year 2025 is 7 / 100.
(3) The childbirth and childcare support rate referred to in paragraph (1) in fiscal year 2026 and subsequent fiscal years is specified by Cabinet Order every two years based on the number obtained by dividing the rate set forth in item (i) by the number set forth in item (ii):
(i) the rate arrived at when 7 percent is multiplied by the rate arrived at when the prospective total number of insured pertaining to all of the Association of Medical Care Systems for the Elderly Aged 75 and older in the relevant fiscal year is divided by the total number of insured pertaining to all of the Association of Medical Care Systems for the Elderly Aged 75 and older in fiscal 2024;
(ii) the number arrived at when the rate set forth in the preceding item is multiplied by the rate arrived at when 93 percent is multiplied by the rate arrived at when the prospective total number of participants for all insurers in the relevant fiscal year is divided by the total number of participants for all insurers in fiscal 2024.
(Childbirth and Childcare Grants)
Article 124-4  (1) The Payment Fund provides childbirth and childcare grants to Insurers in order to cover part of the expenses required for the payment of lump-sum allowance for childbirth and childcare, etc.
(2) The childbirth and childcare grants referred to in the preceding paragraph are covered by childbirth and childcare support money collected by the payment fund pursuant to the provisions of Article 124-2, paragraph (1).
(3) The amount of childbirth and childcare grant to be granted to each insurer pursuant to the provisions of paragraph (1) is the amount calculated pursuant to the provisions of the Medical Insurance Acts.
(Collection and Payment Obligation of Contributions for Administrative Expenses Related to Childbirth and Childcare)
Article 124-5  (1) The Payment Fund collects contributions for the administrative expenses related to childbirth and childcare from Insurers each fiscal year in order to cover the expenses required for the processing of affairs concerning the services listed in Article 139, paragraph (1), item (iii).
(2) An insurer is liable to pay contributions for childbirth and childcare related office expenses.
(Amount of Contributions for Administrative Expenses Related to Childbirth and Childcare)
Article 124-6  The amount of contributions for childbirth and childcare related office expenses collected from each Insurer pursuant to the provisions of paragraph (1) of the preceding Article is the amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, based on the estimated amount of expenses required for the processing of affairs concerning the services of the Payment Fund set forth in Article 139, paragraph (1), item (iii) in the relevant fiscal year, in accordance with the estimated number of subscribers pertaining to each Insurer, as specified by Order of the Ministry of Health, Labour and Welfare.
(Notification)
Article 124-7  (1) Insurers must, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, notify the Payment Fund of the amount of expenses required for the payment of lump-sum allowance for childbirth and childcare, etc. pertaining to the relevant insurers in each fiscal year and other matters specified by Order of the Ministry of Health, Labour and Welfare.
(2) A Association of Medical Care Systems for the Elderly Aged 75 and older must, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, notify the Payment Fund of the number of insured pertaining to the Association of Medical Care Systems for the Elderly Aged 75 and older in each fiscal year and other matters specified by Order of the Ministry of Health, Labour and Welfare.
(Application Mutatis Mutandis)
Article 124-8  The provisions of Article 41 and Articles 43 through 46 apply mutatis mutandis to childbirth and childcare support benefits and contributions for childbirth and childcare related office expenses. In this case, the necessary technical replacement of terms is specified by Cabinet Order.
Subsection 6 Miscellaneous Provisions
Article 124-9  (1) The Old-Old Subsidy granted by the Payment Fund to each Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of Article 100, paragraph (1) and the childbirth and childcare support benefits collected by the Payment Fund from each Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of Article 124-2, paragraph (1) are to be offset.
(2) Medical Care Assistance for the Elderly Aged 75 and over, etc. and contributions for childbirth and childcare related office expenses collected by the Payment Fund from Insurers pursuant to the provisions of Article 118, paragraph (1) and Article 124-5, paragraph (1) and childbirth and childcare grants granted by the Payment Fund to Insurers pursuant to the provisions of Article 124-4, paragraph (1) are to be offset.
Section 5 Healthcare Services for the Elderly
(Healthcare Services for the Elderly)
Article 125  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older must endeavor to provide health education, health counseling, health checkups, and health guidance, as well as support for the insured's self-help efforts pertaining to health management and the prevention of diseases, and other services necessary for the maintenance and promotion of the health of the insured (hereinafter referred to as "health services for the elderly"), in accordance with the mental and physical characteristics of elderly persons.
(2) A Association of Medical Care Systems for the Elderly Aged 75 and older is to provide health services for the elderly in an appropriate and effective manner by making use of medical insurance-related information.
(3) In providing health services for the elderly, a Association of Medical Care Systems for the Elderly Aged 75 and older is to, in coordination with municipalities and insurers, and in light of the physical, mental and social characteristics of elderly persons, provide health services for the elderly in an integrated manner with the services provided by municipalities according to the mental and physical characteristics of elderly persons as prescribed in Article 82, paragraph (5) of the National Health Insurance Act (referred to as "national health insurance health services" in paragraph (1) of the following Article) and the community support projects provided by the Long-Term Care Insurance Act Article 115-45, paragraphs (1) through (3) (referred to as "community support projects" in paragraph (1) of the following Article), in order to provide health services for the elderly in an effective, efficient and meticulous manner according to the circumstances of the insured, in coordination with municipalities.
(4) In providing health services for the elderly, a Association of Medical Care Systems for the Elderly Aged 75 and older must endeavor to specify the matters concerning the coordination between the Association of Medical Care Systems for the Elderly Aged 75 and older and the municipality in the regional plan provided for in Article 291-7 of the Local Autonomy Act (referred to as the "regional plan" in paragraph (1) of the following Article), so as to promote the provision of health services for the elderly in an effective, efficient, and detailed manner according to the circumstances of each insured.
(5) A Association of Medical Care Systems for the Elderly Aged 75 and older may provide necessary services such as the lending of equipment necessary for medical treatment in the insured and other services necessary to improve the medical treatment environment in the insured, services necessary for the medical care benefit for the old-old, and the lending of funds pertaining to expenses for medical treatment in the insured.
(6) The Minister of Health, Labour and Welfare, with regard to health services for the elderly provided by a Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of paragraph (1), is to provide necessary support, such as the publication of guidelines and the provision of information, in order to ensure the appropriate and effective implementation thereof.
(7) The guidelines referred to in the preceding paragraph are to provide for the following particulars:
(i) basic matters concerning the effective and efficient implementation of health services for the elderly;
(ii) particulars concerning the efforts made by a Association of Medical Care Systems for the Elderly Aged 75 and older and a municipality entrusted pursuant to the provisions of the first sentence of paragraph (1) of the following Article for the effective and efficient implementation of health services for the elderly;
(iii) particulars concerning support for a Association of Medical Care Systems for the Elderly Aged 75 and older and a municipality entrusted pursuant to the provisions of the first sentence of paragraph (1) of the following Article for the effective and efficient implementation of health services for the elderly;
(iv) matters concerning cooperation between a Association of Medical Care Systems for the Elderly Aged 75 and older and a municipality for the effective and efficient implementation of health services for the elderly;
(v) particulars concerning coordination between the Association of Medical Care Systems for the Elderly Aged 75 and older and the relevant organizations and groups in the community for the effective and efficient implementation of health services for the elderly;
(vi) other matters to be taken into consideration for the effective and efficient implementation of health services for the elderly.
(8) The guidelines referred to in paragraph (6) must be in harmony with the health checkup guidelines prescribed in Article 9, paragraph (1) of the Health Promotion Act, the guidelines prescribed in Article 82, paragraph (11) of the National Health Insurance Act, and the basic guidelines prescribed in Article 116, paragraph (1), Long-Term Care Insurance Act.
(Entrustment of Health Services for the Elderly to Municipalities)
Article 125-2  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older may entrust a Municipality that is a member of the Association of Medical Care Systems for the Elderly Aged 75 and older with the implementation of part of its elderly health services based on the Regional Plan of the Association of Medical Care Systems for the Elderly Aged 75 and older, and the entrusted Municipality is to, from the viewpoint of ensuring the effective and efficient implementation of the elderly health services for the insured, establish basic policies concerning the implementation of the services, including the ideal way of implementing the services in an integrated manner with national health insurance health services and community support projects. In this case, the Association of Medical Care Systems for the Elderly Aged 75 and older may provide the entrusted Municipality with copies of its own records concerning medical treatment, health checkups, or health guidance pertaining to the insured, and other information specified by Order of the Order of the Ministry of Health, Labour and Welfare as necessary for the effective and efficient implementation of the elderly health services, to the extent necessary for the implementation of the entrusted elderly health services.
(2) A person who is or was an official of a municipality entrusted pursuant to the provisions of the first sentence of the preceding paragraph must not, without justifiable grounds, divulge any individual secrets that have come to their knowledge in relation to the implementation of health services for the elderly.
(Provision of Information on Health Services for the Elderly)
Article 125-3  (1) An Association of Medical Care Systems for the Elderly Aged 75 and older and a Municipality which has been entrusted by the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the first sentence of paragraph (1) of the preceding Article may, when there is a person who has obtained eligibility as an insured of the Association of Medical Care Systems for the Elderly Aged 75 and older (limited to a person who had belonged to an Insurer), request the Insurer to which the insured belonged to provide a copy of records concerning Special health examinations or Specific Health Guidance pertaining to the insured preserved by the Insurer.
(2) If a Association of Medical Care Systems for the Elderly Aged 75 and older conducts an inventory and analysis of the physical, mental, and social conditions of each insured and finds it necessary for the effective and efficient implementation of health and welfare services for the elderly in each insured, it may request a Municipality and other Association of Medical Care Systems for the Elderly Aged 75 and older to provide information, etc. concerning medical care and long-term care pertaining to the insured (meaning information concerning medical treatment, a copy of records concerning health checkups or health guidance, or a copy of records concerning Special health examinations or specified health guidance pertaining to the insured, information concerning medical treatment under the provisions of the National Health Insurance Act, or information concerning health and medical services or welfare services under the provisions of the Long-Term Care Insurance Act; hereinafter the same applies in this Article and the following Article) and other information specified by Order of the Order of the Ministry of Health, Labour and Welfare as necessary for the effective and efficient implementation of health and welfare services for the elderly.
(3) If a municipality is entrusted with elderly health services provided by a Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the first sentence of paragraph (1) of the preceding Article, and finds it necessary from the viewpoint of organizing and analyzing the physical, mental, and social conditions of each insured and implementing elderly health services for the insured in an effective and efficient manner, the municipality may request other municipalities and the Association of Medical Care Systems for the Elderly Aged 75 and older to provide information, etc. concerning medical care and nursing care pertaining to the insured and other information specified by Order of the Order of the Ministry of Health, Labour and Welfare as necessary for implementing elderly health services in an effective and efficient manner.
(4) Insurers, municipalities, and Association of Medical Care Systems for the Elderly Aged 75 and older that have been requested to provide a copy of records or data pursuant to the provisions of the preceding three paragraphs must provide a copy of the records or data pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(5) A Municipality which has been entrusted pursuant to the provisions of the first sentence of paragraph (1) of the preceding Article may, in order to provide Health Services for the Elderly in an effective and efficient manner and in a meticulous manner that corresponds to the circumstances of the insured, utilize, in addition to copies of records or information provided pursuant to the provisions of the preceding paragraph, records that it holds concerning Special health examinations or Specific Health Guidance pertaining to the insured, information concerning medical treatment under the provisions of the National Health Insurance Act, or information concerning health and medical services or welfare services under the provisions of the Long-Term Care Insurance Act.
(Entrustment of Health Services for the Elderly to Relevant Organizations or Groups)
Article 125-4  (1) A Association of Medical Care Systems for the Elderly Aged 75 and older may entrust part of its health services for the elderly to a relevant organization or relevant organization (excluding a prefecture or municipality; hereinafter the same applies in this Article) that is found to be capable of implementing health services for the elderly appropriately and reliably. In this case, the Association of Medical Care Systems for the Elderly Aged 75 and older may provide to the entrusted relevant organization or relevant organization, within the scope necessary for implementing the entrusted health services for the elderly, information, etc. concerning medical care and nursing care for the insured which it possesses or which it has received pursuant to the provisions of paragraph (4) of the preceding Article, and any other information specified by Order of the Order of the Ministry of Health, Labour and Welfare as necessary for implementing health services for the elderly effectively and efficiently.
(2) A Municipality that has been entrusted pursuant to the provisions of the first sentence of Article 125-2, paragraph (1) may entrust part of the entrusted health services for the elderly to a Relevant Organization or Relevant Organization that is found to be capable of implementing the health services for the elderly appropriately and reliably. In this case, the Municipality may provide the entrusted Relevant Organization or Relevant Organization, to the extent necessary to implement the entrusted health services for the elderly, with the Information, etc. on medical care and nursing care for the insured which it possesses or which it has been provided pursuant to the provisions of the second sentence of the same paragraph or paragraph (4) of the preceding Article, and any other Information specified by Order of Order of the Ministry of Health, Labour and Welfare as necessary for implementing the health services for the elderly effectively and efficiently.
(3) It is prohibited for the current or former officer or employee of a relevant organization or organization entrusted pursuant to the first sentence of paragraph (1) or the first sentence of the preceding paragraph to divulge any individual confidential information learned in the course of implementing elderly health services, without a legitimate reason for doing so.
Section 6 Examination Committee for Medical Fees for Old-Old Healthcare
(Review Committee)
Article 126  (1) A Medical Fee Review Committee for Old-Old Healthcare is established within the NHI Federations in order to review medical bills as entrusted pursuant to the provisions of Article 70, paragraph (4).
(2) Notwithstanding the provisions of the preceding paragraph, a NHI federation with a review committee as prescribed in Article 87 of the National Health Insurance Act may have the review committee review medical bills pertaining to medical care for the elderly.
(Mutatis Mutandis Application of the National Health Insurance Act)
Article 127  The provisions of Articles 88 through 90 of the National Health Insurance Act apply mutatis mutandis to the Examination Committee for Old-Old Medical Treatment Fees.
Section 7 Request for Examination
(Request for Examination)
Article 128  (1) A person who is dissatisfied with a disposition concerning a medical care benefit for the old-old (including a disposition concerning a request pursuant to the provisions of Article 54, paragraphs (3) and (5)) or a disposition concerning insurance premiums or any other money to be collected pursuant to the provisions of this Chapter (limited to those collected by a Municipality and a Association of Medical Care Systems for the Elderly Aged 75 and older) may make a request for examination to the Certification Committee for Old-Old Healthcare.
(2) With regard to postponement of expiry of prescription period and renewal of prescription period, the request for examination referred to in the preceding paragraph is deemed to be a demand by litigation.
(Establishment of the Review Board)
Article 129  The Certification Committee for Old-Old Healthcare is established in each prefecture.
(Mutatis Mutandis Application of the National Health Insurance Act)
Article 130  The provisions of Articles 93 through 103 of the National Health Insurance Act apply mutatis mutandis to the Certification Committee for Old-Old Healthcare. In this case, the necessary technical replacement of terms is specified by Cabinet Order.
Section 8 Assistance for Healthcare Services for the Elderly
(Assistance for Healthcare Services for the Elderly)
Article 131  In order to stabilize the administration of medical care for the elderly, the NHI Federations and designated corporations must endeavor to carry out liaison and coordination between the Association of Medical Care Systems for the Elderly Aged 75 and older (in the case of the NHI Federations, this includes between the Association of Medical Care Systems for the Elderly Aged 75 and older and municipalities that have been entrusted by the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the first sentence of Article 125, paragraph (5), and also includes between municipalities that have been entrusted by the Association of Medical Care Systems for the Elderly Aged 75 and older) in relation to research and studies on health services for the elderly and services prescribed in the medical care benefit, services for the optimization of expenses required for the old-old community, and other services (hereinafter referred to as "health services for the elderly, etc." in this Article) provided by the National Institute of Health and Welfare, and in relation to the implementation of health services for the elderly, etc., as well as to dispatch persons with specialized skills or knowledge, provide information, analyze and evaluate the status of implementation of health services for the elderly, etc., and provide other necessary assistance concerning health services for the elderly, etc. Article 125-2, paragraph (1).
(Measures by the State and Local Governments)
Article 132  The national government and local governments must endeavor to give advice, provide information, and take other measures necessary to promote the services provided by NHI federations and designated corporations pursuant to the provisions of the preceding Article.
Section 9 Miscellaneous Provisions
(Advice of Prefectures)
Article 133  (1) A prefecture is to provide a Association of Medical Care Systems for the Elderly Aged 75 and older or a municipality with necessary advice and appropriate assistance so that the operation of the medical insurance system for the elderly is carried out soundly and smoothly.
(2) If a Association of Medical Care Systems for the Elderly Aged 75 and older intends to provide the benefits set forth in Article 56, item (iii) or in other cases specified by Cabinet Order, it must consult with the prefectural governor in advance.
(Collection of Reports)
Article 134  (1) The Minister of Health, Labour and Welfare or the prefectural governor may, when they find it necessary for the enforcement of this Act with regard to a Association of Medical Care Systems for the Elderly Aged 75 and older or a municipality, collect reports on the status of its services and assets, or have the relevant officials inspect the status on site.
(2) If the Minister of Health, Labour and Welfare or the prefectural governor finds it necessary for the calculation of the amount of Young-Old Payments, etc., Medical Care Assistance for the Elderly Aged 75 and over, etc., and contributions for childbirth and childcare related office expenses, the Minister of Health, Labour and Welfare or the prefectural governor may collect reports on the services from Insurers (or prefectures in the case of national health insurance programs) or have the relevant officials inspect the situation on site.
(3) The provisions of Article 16-7, paragraph (2) apply mutatis mutandis to the inspection pursuant to the provisions of the preceding two paragraphs, and the provisions of paragraph (3) of the same Article apply mutatis mutandis to the authority pursuant to the provisions of the preceding two paragraphs.
(Reporting on the Status of Operations)
Article 135  (1) The Association of Medical Care Systems for the Elderly Aged 75 and older or the Federation of National Health Insurance Associations must, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, report to the prefectural governor the status of activities pertaining to medical care for the elderly (in the case of a Association of Medical Care Systems for the Elderly Aged 75 and older, including the status of activities for which the head of the Association of Medical Care Systems for the Elderly Aged 75 and older (in the case of a Association of Medical Care Systems for the Elderly Aged 75 and older which has a board of directors in lieu of the head pursuant to the provisions of Article 291-13 of the Local Autonomy Act as applied mutatis mutandis pursuant to Article 287-3, paragraph (2) of the same Act, the board of directors; the same applies in the following paragraph) receives reports from the municipality pursuant to the provisions of the following paragraph).
(2) A Municipality, pursuant to the provisions of a Order of the Ministry of Health, Labour and Welfare, must report the status of its services pertaining to Old-Old Healthcare to the head of a Association of Medical Care Systems for the Elderly Aged 75 and older.
(Free Certification Concerning Family Registers)
Article 136  The mayor of a municipality (including the mayor of a special ward, and in the case of a designated city in the Article 252-19, paragraph (1) of the Local Autonomy Act, the mayor of a ward or mayor of an administratively consolidated ward) may, pursuant to the provisions of Ordinances of the relevant municipality, issue a certificate concerning the family register of a person who is or was a insured or insured to a person who is eligible for a Association of Medical Care Systems for the Elderly Aged 75 and older or an medical care benefit for Old-Old Persons, free of charge.
(Investigation of insured)
Article 137  (1) If the Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary in relation to eligibility as an insured, an medical care benefit for the old-old, and insurance premiums, it may order the insured, the spouse of the insured, or the householder or any other member or former member of the household to which the insured belongs to submit or present a document or any other item, or may have its official ask them questions.
(2) A Municipality, when it finds it necessary in relation to the collection of insurance premiums, may order the insured, the spouse of the insured, or the householder or any other member or former member of the household to which the insured belongs to submit or present a document or any other article, or may have its personnel question such person.
(3) The provisions of Article 16-7, paragraph (2) apply mutatis mutandis to questions pursuant to the provisions of the preceding two paragraphs, and the provisions of paragraph (3) of the same Article apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding two paragraphs.
(Provision of Materials)
Article 138  (1) If the Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary in relation to eligibility as an insured, an medical care benefit for the Old-Old, and insurance premiums, it may request a municipality or any other public agency or pension insurer to provide access to necessary documents or to provide necessary materials, or may request a bank, trust company, or any other institution, or the employer of an insured, or any other relevant person to make a report, with regard to the particulars necessary for confirming that the grounds for receiving the medical care benefit for the Old-Old in the insured were caused by an act of a third party, the status of assets or income of the insured, the spouses of an insured, the householder of the household to which an belongs, or any other person belonging to the household, or the status of payment of the Old Age, etc., pension benefit provided for in the Article 107, paragraph (2) to an insured. insured.
(2) If a Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary in relation to eligibility as an insured, it may request other Association of Medical Care Systems for the Elderly Aged 75 and older and insurers (or municipalities in the case of national health insurance programs) to provide necessary materials, including the names and addresses of the insured and subscribers of medical care for the elderly provided by other Association of Medical Care Systems for the Elderly Aged 75 and older (or the insured domiciled within the area of the relevant municipality in the case of national health insurance programs), and the name and location of the applicable place of business as prescribed in Article 3, paragraph (3) of the Health Insurance Act.
(3) A Municipality, when it finds it necessary in relation to the collection of insurance premiums, may request public agencies or Pension Insurers to provide access to necessary documents or to provide necessary materials, or may request a report from banks, trust companies, other institutions, employers of the insured, or other relevant persons, with regard to the status of assets or income of the insured, the spouses of the insured, or the head of the household or other members of the household to which the insured belongs, or the status of payment of an Old Age, etc., pension benefit as prescribed by the Article 107, paragraph (2) to the insured.
Chapter V Services Related to the Medical Care System for the Elderly of the Health Insurance Claims Review & Reimbursement Services
(Operations of the Payment Fund)
Article 139  (1) In addition to the services prescribed in Article 15 of the Health Insurance Claims Review & Reimbursement Services Act, the Payment Fund performs the following services in order to achieve the purpose prescribed in Article 1:
(i) operations to collect Young-Old Payments, etc. from an Insurer (or a prefecture in the case of national health insurance; hereinafter the same applies in this Chapter, except in the following Article) and to provide Young-Old Grants to the Insurer, and operations incidental thereto;
(ii) services for collecting Medical Care Assistance for the Elderly Aged 75 and over, etc. from insurers and providing the Old-Old Subsidy to the Association of Medical Care Systems for the Elderly Aged 75 and older, and services incidental thereto;
(iii) services for collecting childbirth and childcare support grants from insurers, collecting contributions for childbirth and childcare related office expenses from insurers, and providing childbirth and childcare subsidies to insurers, and services incidental to these services; and (iii) services for collecting childbirth and childcare support grants from insurers, collecting contributions for childbirth and childcare related office expenses from insurers, and providing childbirth and childcare subsidies to Association of Medical Care Systems for the Elderly Aged 75 and older, and services incidental to these services.
(2) The Payment Fund may carry out activities that contribute to achieving the purpose prescribed in Article 1 with the authorization of the Minister of Health, Labour and Welfare to the extent that the activities set forth in the preceding paragraph are not hindered.
(3) The operations prescribed in the preceding two paragraphs are referred to as the operations related to the medical care system for the elderly.
(Entrustment of Operations)
Article 140  The Payment Fund, with the authorization of the Minister of Health, Labour and Welfare, may entrust part of the functions related to the medical care system for the elderly to an organization which Insurers belong to and which is specified by the Minister of Health, Labour and Welfare.
(Operational Method Statement)
Article 141  (1) The Payment Fund, with regard to the Services Related to Medical Care Systems for the Elderly, must prepare a statement of operational procedures and obtain the authorization of the Minister of Health, Labour and Welfare prior to the commencement of the services. The same applies when the statement is changed.
(2) The particulars to be stated in the statement of operational procedures referred to in the preceding paragraph are specified by Order of the Order of the Ministry of Health, Labour and Welfare.
(Reports)
Article 142  (1) The Payment Fund may request Insurers to submit documents and other items in each fiscal year, in addition to requesting reports on the number of subscribers, the implementation status of Special health examinations, etc., and other particulars specified by Order of the Ministry of Health, Labour and Welfare, when the Fund finds it necessary to do so in relation to the business of collecting Young-Old Payments from Insurers prescribed in Article 139, paragraph (1), item (i), the business of collecting Medical Care Assistance for the Elderly Aged 75 and over from Insurers prescribed in item (ii) of the same paragraph, and the business of collecting contributions for childbirth and childcare related office expenses from Insurers prescribed in item (iii) of the same paragraph.
(2) The Payment Fund, when it finds it necessary in relation to the business of collecting childbirth and childcare support benefits from a Association of Medical Care Systems for the Elderly Aged 75 and older prescribed in Article 139, paragraph (1), item (iii), may request the Association of Medical Care Systems for the Elderly Aged 75 and older to submit documents and other items.
(Separate Accounting)
Article 143  The Payment Fund must establish a special account for the accounting for Services Related to Medical Care Systems for the Elderly, separately from the accounting for other services, for each of the services set forth in Article 139, paragraph (1), item (i), the services set forth in items (ii) and (iii) of that paragraph, and the services prescribed in paragraph (2) of that Article.
(Approval of Budgets)
Article 144  The Payment Fund must prepare a budget, business plan, and funding plan for each business year with regard to the Functions Related to Medical Care Systems for the Elderly, and obtain the authorization of the Minister of Health, Labour and Welfare prior to the commencement of the relevant business year. The same applies when making any change to these.
(Financial Statements)
Article 145  (1) The Payment Fund must prepare the inventory of assets, balance sheets, and profit and loss statement (hereinafter referred to as the "Financial Statement") for each business year with regard to the Functions Related to Medical Systems for the Elderly, and must submit them to the Minister of Health, Labour and Welfare within three months after the end of the relevant business year and obtain the approval of the Minister.
(2) The Payment Fund, when submitting the financial statement to the Minister of Health, Labour and Welfare pursuant to the provisions of the preceding paragraph, must attach thereto a business report and statement of accounts prepared according to the classification of budget for the relevant business year and the written opinion of the inspector on the financial statement and statement of accounts pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare.
(3) The Payment Fund, when it has obtained the approval of the Minister of Health, Labour and Welfare pursuant to the provisions of paragraph (1), must give public notice of the Financial Statement or summary thereof in official gazettes without delay, and must keep the Financial Statement and annexed detailed statement as well as the business report, statement of accounts, and written opinions of the auditors set forth in the preceding paragraph at its principal office and make them available for public inspection for a period specified by Order of Order of the Ministry of Health, Labour and Welfare.
(Handling of Profits and Losses)
Article 146  (1) The Payment Fund, with regard to the medical services for the elderly (excluding the services prescribed in Article 139, paragraph (2); the same applies in the following paragraph and paragraph (1) of the following Article), in each business year, when profits have accrued based on the profit and loss calculation, must offset any losses carried over from the previous business year, and if there is any surplus even after offsetting the losses, the Payment Fund must keep this surplus amount as a reserve fund.
(2) The Payment Fund, with regard to the Services Related to Medical Care System for the Elderly, in each business year when a loss is incurred based on the calculation of profits and losses, must account for the loss by reducing the amount of the reserve fund under the provisions of the preceding paragraph, and if there is still a shortfall, the amount of the shortfall must be accounted for as a loss carried forward.
(3) The Payment Fund, limited to the amount specified in the budget, may allocate the reserve funds pursuant to the provisions of paragraph (1) to the expenses required for the business of providing Young-Old Subsidies to Insurers prescribed in Article 139, paragraph (1), item (i), the business of providing Old-Old Subsidies to Association of Medical Care Systems for the Elderly Aged 75 and older prescribed in item (ii) of the same paragraph, the business of providing Childbirth and Childcare Subsidies to Insurers prescribed in item (iii) of the same paragraph, or the business to be carried out by obtaining approval pursuant to the provisions of paragraph (2) of the same Article.
(Borrowings and Bonds)
Article 147  (1) The Payment Fund, with regard to the Services Related to Medical Care Systems for the Elderly, may operate long-term borrowings or short-term borrowings, or issue bond certificates, with the authorization of the Minister of Health, Labour and Welfare.
(2) The long-term borrowings and bond certificates under the preceding paragraph must be redeemed within two years.
(3) The short-term borrowings pursuant to the provisions of paragraph (1) must be repaid within the relevant project year; provided, however, that when the short-term borrowings cannot be repaid due to a lack of funds, only the amount that cannot be repaid may be refinanced with the approval of the Minister of Health, Labour and Welfare.
(4) Short-term borrowings that have been refinanced pursuant to the proviso to the preceding paragraph must be repaid within one year.
(5) If the Payment Fund issues bonds pursuant to the provisions of paragraph (1), it may do so by means of a discount.
(6) The creditors of the bonds under the provisions of paragraph (1) have the right to have their claims satisfied out of the assets of the payment fund in preference over other creditors.
(7) The order of the statutory lien set forth in the preceding paragraph is to be next to the general statutory lien under the provisions of the Civil Code (Act No. 89 of 1896).
(8) The Payment Fund may, with the authorization of the Minister of Health, Labour and Welfare, entrust all or part of the affairs concerning the issuance of bond certificates under paragraph (1) to a bank or a trust company.
(9) The provisions of Article 705, paragraphs (1) and (2), and Article 709 of the Companies Act (Act No. 86 of 2005) apply mutatis mutandis to a bank or trust company entrusted with business pursuant to the provisions of the preceding paragraph.
(10) Beyond what is provided for in paragraph (1), paragraph (2), and paragraph (5) through the preceding paragraph, necessary matters concerning the bond certificates referred to in paragraph (1) are specified by Cabinet Order.
(Government Guarantee)
Article 148  Notwithstanding the provisions of Article 3 of the Act on Restrictions on Financial Assistance by the Government to Corporations (Act No. 24 of 1946), when the government finds it necessary for the smooth delivery of young-old subsidies, old-old subsidies, and childbirth and childcare subsidies by the Payment Fund within the amount approved by a National Diet resolution, the government may guarantee obligations pertaining to long-term borrowings, short-term borrowings, or bonds of the Payment Fund pursuant to the provisions of the preceding Article within the period found to be necessary.
(Investment of Surplus Funds)
Article 149  The Payment Fund must not invest any surplus funds that arise in the course of operations pertaining to the Functions Related to the Medical Care System for the Elderly, except in the following ways:
(i) holding of Japanese government bonds and other securities designated by the Minister of Health, Labour and Welfare;
(ii) making deposits with banks and other financial institutions designated by the Minister of Health, Labour and Welfare;
(iii) money trust into financial institutions engaged in trust business (meaning financial institutions that have obtained the authorization under Article 1, paragraph (1) of the Act on Engagement in Trust Business Activities by Financial Institutions (Act No. 43 of 1943)).
(Consultation)
Article 150  The Minister of Health, Labour and Welfare must consult with the Minister of Finance in advance in any of the following cases:
(i) when intending to grant approval as a Article 147, paragraph (1), paragraph (3) or paragraph (8) Site;
(ii) when intending to make a designation referred to in item (i) or (ii) of the preceding Article.
(Delegation to the Order of the Ministry of Health, Labour and Welfare)
Article 151  Beyond what is provided for in this Chapter, the necessary matters concerning the finance and accounting of the Payment Fund pertaining to the Services Related to Medical Care Systems for the Elderly are specified by Order of the Ministry of Health, Labour and Welfare.
(Collection of Reports)
Article 152  (1) The Minister of Health, Labour and Welfare or the prefectural governor may, when finding it necessary in relation to the Services Related to Medical Systems for the Elderly with regard to a person entrusted pursuant to the provisions of the Reimbursement Services or Article 140 (hereinafter referred to as an "entrusted person"), collect reports on the status of the services or property of the entrusted person or have the relevant officials inspect the status on site; provided, however, that with regard to an entrusted person, this is limited to the scope of the entrusted services.
(2) The provisions of Article 16-7, paragraph (2) apply mutatis mutandis to the inspection under the provisions of the preceding paragraph, and the provisions of paragraph (3) of the same Article apply mutatis mutandis to the authority under the provisions of the preceding paragraph.
(3) When a prefectural governor finds it necessary to render a disposition under the provisions of Article 29 of the Health Insurance Claims Review & Reimbursement Services Act with regard to the Payment Fund's Services Related to the Medical Care System for the Elderly, or when a prefectural governor finds it necessary to render a disposition under the provisions of Article 11, paragraph (2) or paragraph (3) of the same Act with regard to the president, directors, or auditors of the Payment Fund with regard to the Services Related to the Medical Care System for the Elderly, the prefectural governor must notify the Minister of Health, Labour and Welfare to that effect with the reason attached thereto.
(Special Provisions for Application of the Health Insurance Claims Review & Reimbursement Services Act)
Article 153  With regard to the application of the provisions of Article 11, paragraphs (2) and (3) of the Health Insurance Claims Review & Reimbursement Services Act, an order prescribed in Article 101, paragraph (1) is deemed to be an order prescribed in Article 29 of the same Act, and with regard to the application of the provisions of Article 32, paragraph (2) of the same Act, the services related to the medical care system for the elderly are deemed to be the services prescribed in Article 15 of the same Act.
(Request for Examination)
Article 154  Any person who is dissatisfied with the disposition or inaction of the Payment Fund pursuant to this Act may request the Minister of Health, Labour and Welfare for an examination. In this case, with regard to the application of the provisions of Article 25, paragraphs (2) and (3), Article 46, paragraphs (1) and (2), Article 47, and Article 49, paragraph (3) of the Administrative Appeal Act (Act No. 68 of 2014), the Minister of Health, Labour and Welfare is deemed to be the higher administrative authority of the Payment Fund.
Chapter VI Medical Services for the Elderly by the National Health Insurance Federation
(Operations of NHI Federations)
Article 155  (1) In addition to the operations under the provisions of the National Health Insurance Act, a Federation of Health Insurance Associations performs the operations of examination and payment of claims for expenses required for benefits for medical treatment provided based on entrustment from a Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of Article 70, paragraph (4) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 78, paragraph (8)), as well as dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, and medical expenses for home-nursing.
(2) In addition to the operations prescribed in the preceding paragraph, a NHI federation may conduct the following operations in order to contribute to the smooth operation of medical care for elderly persons:
(i) affairs concerning the collection or receipt of compensation for damages to be paid to third parties based on an entrustment from a Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of Article 58, paragraph (3);
(ii) beyond what is set forth in the preceding item, a project that contributes to the smooth operation of Old-Old Healthcare.
(Special Provisions for Voting Rights)
Article 156  With regard to the business conducted by NHI federations pursuant to the provisions of the preceding Article (hereinafter referred to as "medical services for the elderly"), notwithstanding the provisions of Article 29 of the National Health Insurance Act as applied mutatis mutandis pursuant to Article 86 of the same Act, as specified by Order of Order of the Ministry of Health, Labour and Welfare, special provisions concerning voting rights may be established by the constitution.
(Separate Accounting)
Article 157  A NHI federation must separate its accounting for medical services for the elderly from its other accounting.
Chapter VII Miscellaneous Provisions
(Insurer Council)
Article 157-2  (1) For each prefecture, Insurers and Association of Medical Care Systems for the Elderly Aged 75 and older are to jointly establish a Council of Insurers in order to promote necessary projects for the maintenance of the health of subscribers in old age and the optimization of medical expenses as well as to ensure the smooth operation of the medical care system for the elderly and cooperation in the operation.
(2) The insurer council referred to in the preceding paragraph performs the following services:
(i) liaison and coordination among insurers and other relevant persons concerning the implementation of Special health examinations, etc., the operation of the medical care system for the elderly, and other matters;
(ii) necessary advice or assistance to the insurer;
(iii) investigating and analyzing information on the expenses required for medical services and other particulars specified by Order of the Order of the Ministry of Health, Labour and Welfare;
(iv) investigation and analysis concerning the evaluation of the performance of the prefectural plan for regulating medical expenses.
(3) The Minister of Health, Labour and Welfare is to provide necessary support to ensure that the Council of Insurers smoothly carries out the services set forth in the items of the preceding paragraph.
(Promotion of Research and Development)
Article 158  In order to ensure the sound and smooth implementation of health services for the elderly and the services prescribed by the Article 125, paragraph (5), the national government must endeavor to promote research and development of nursing and other medical care, functional training, etc. according to the mental and physical characteristics of elderly persons, and research and development of equipment for facilitating elderly persons in their daily lives and equipment for functional training, which are intended for use by persons whose mental and physical functions have deteriorated due to illness or injury, etc.
(Order of Statutory Liens)
Article 159  The order of statutory liens on insurance premiums and other money to be collected pursuant to the provisions of this Act comes after national taxes and local taxes.
(Prescription)
Article 160  (1) The right to collect insurance premiums and any other money to be collected pursuant to the provisions of this Act or to receive a refund thereof, and the right to receive an old-old medical care benefit are extinguished by prescription when two years have elapsed from the time when these rights can be exercised.
(2) A notice or demand for the collection of insurance premiums or any other money to be collected pursuant to the provisions of this Act has the effect of renewing the prescription period.
(Time Limits for Assessment Decisions)
Article 160-2  (1) An assessment and determination of insurance premiums may not be made on or after the day on which two years have elapsed from the day following the first due date for payment of insurance premiums in the relevant fiscal year (meaning the due date for payment of insurance premiums pursuant to the provisions of this Act or Prefectural Ordinance under this Act, and in cases where it becomes possible to impose insurance premiums after the due date, the day on which it becomes possible to impose the insurance premiums; the same applies in the following paragraph).
(2) Notwithstanding the provisions of the preceding paragraph, an assessment and decision to reduce the amount of insurance premiums in the case where it is found, after an assessment and decision of insurance premiums is made, that adjustment of the applicable relationship between the insured and medical insurance laws (excluding the National Health Insurance Act) is required due to grounds not attributable to insured, may be made on or after the day on which two years have elapsed from the day following the due date of the first insurance premiums in the relevant fiscal year, until the day on which a period equivalent to the period found necessary for the adjustment has elapsed from the day following the due date of the first insurance premiums in the relevant fiscal year.
(Calculation of Period)
Article 161  The provisions of the Civil Code concerning periods of time apply mutatis mutandis to the computation of periods of time prescribed in this Act or in orders based on this Act.
(Restrictions on the Use of insured Numbers)
Article 161-2  (1) An Minister of Health, Labour and Welfare, a Association of Medical Care Systems for the Elderly Aged 75 and older, a medical institution providing services covered by health insurance, etc., a designated home-nursing provider or any other person specified by Order of the Order of the Ministry of Health, Labour and Welfare as a person who uses an insured number, etc. (meaning an insurer's number (meaning a number specified by the Minister of Health, Labour and Welfare for each Association of Medical Care Systems for the Elderly Aged 75 and older as a number for identifying an Association of Medical Care Systems for the Elderly Aged 75 and older in the medical services for the old-old) and an insured number (meaning a number specified by the Association of Medical Care Systems for the Elderly Aged 75 and older for each insured as a number for managing the qualifications of an insured; the same applies hereinafter in this Article); hereinafter the same applies in this Article) for the implementation of the services for medical services for the old-old or affairs related to the services (hereinafter referred to as an "Minister of Health, Labour and Welfare, etc." in this Article) must not request any person to notify the person or any other person of the insured number, etc. unless it is necessary for the implementation of the services or affairs.
(2) A person other than an Minister of Health, Labour and Welfare, etc. must not request any person to notify the person or the insured number, etc. related to the person other than the person, except for cases specified by Order of Order of the Ministry of Health, Labour and Welfare where the use of the insured number, etc. is particularly necessary for the implementation of the services of medical care for the elderly or affairs related to the services.
(3) Except in the following cases, it is prohibited for any person to request a person seeking to offer or offering to offer, or a person that has concluded a contract with, a person selling, leasing, hiring, or other contract (hereinafter referred to as a "contract" in this paragraph) in connection with an action that the person carries out in the course of trade, to announce the insured number, etc. of that person or a person other than that person:
(i) when the Minister of Health, Labour and Welfare, etc. requests notification of the insured number, etc. in the case prescribed in paragraph (1);
(ii) when a person other than the Minister of Health, Labour and Welfare, etc. requests notification of the Order of the Ministry of Health, Labour and Welfare number, etc. in the case specified by Order of the insured prescribed in the preceding paragraph.
(4) Except in the following cases, it is prohibited for any person to engage in the business of constructing a database in which insured numbers, etc. are recorded (meaning a collection of data that includes insured numbers, etc. for a person other than the person in question, which has been systematically organized so as to be searchable using a computer) and the data recorded in that database is intended to be provided to others (hereinafter referred to as a "provided database" in this paragraph):
(i) if the Minister of Health, Labour and Welfare, etc. constitutes the provided database in the case prescribed in paragraph (1);
(ii) when a person other than the Minister of Health, Labour and Welfare, etc. constructs the provided database in cases specified by Order of the Order of the Ministry of Health, Labour and Welfare as prescribed in paragraph (2).
(5) If an act in violation of the provisions of the preceding two paragraphs has been committed and the Minister of Health, Labour and Welfare finds that the person who committed that act is likely to commit an act in violation of those provisions again and again, the Prime Minister may recommend the person who committed that act to discontinue that act or take the necessary measures to ensure that that act will be discontinued.
(6) If a person who has received recommendations under the provisions of the preceding paragraph does not follow the recommendations, the Minister of Health, Labour and Welfare may order the person to follow the recommendations by a set deadline.
(Reports and Inspections)
Article 161-3  (1) On finding that it is necessary to do so in connection with a measure under the provisions of paragraph (5) or (6) of the preceding Article, the Minister of Health, Labour and Welfare, within the scope of what is found to be necessary, may ask a person that there are reasonable grounds to find to be in violation of the provisions of paragraph (3) or (4) of that Article to report on the necessary particulars, and may have the relevant officials enter the office or place of business of that person and ask questions or inspect its books, documents, and any other articles.
(2) The provisions of Article 16-7, paragraph (2) apply mutatis mutandis to questions and inspections pursuant to the provisions of the preceding paragraph, and the provisions of paragraph (3) of the same Article apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding paragraph.
(Supervision of NHI Federations)
Article 162  When the provisions of Articles 106 and 108 of the National Health Insurance Act are applied to NHI federations, the term "services" in these provisions is deemed to be replaced with "services (including medical services for the elderly as prescribed in Article 156 of the Act on Assurance of Medical Care for Elderly People (Act No. 80 of 1982))".
(Delegation of Authority)
Article 163  (1) The authority of the Minister of Health, Labour and Welfare provided for in this Act may be delegated to the Director-General of a Regional Bureau of Health and Welfare pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(2) The authority delegated to the Director-General of a Regional Bureau of Health and Welfare pursuant to the provisions of the preceding paragraph may be delegated to the Director-General of a Regional Branch Bureau of Health and Welfare pursuant to the provisions of Order of the Order of the Ministry of Health, Labour and Welfare.
(Coordination between the Minister of Health, Labour and Welfare and Prefectural Governors)
Article 164  When the Minister of Health, Labour and Welfare or prefectural governors perform the affairs prescribed in this Act, they are to do so in close coordination with each other.
(Classification of Administrative Processes)
Article 165  Affairs that are to be administered by a prefecture pursuant to the provisions of Article 44, paragraph (4) (including as applied mutatis mutandis pursuant to Article 124, Article 124-8 and Article 10 of the Supplementary Provisions), Article 61, paragraphs (1) and (2), Article 66, paragraph (1) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 82, paragraph (6)) and paragraph (2) (including as applied mutatis mutandis pursuant to Article 72, paragraph (2), Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 82, paragraph (6)), Article 70, paragraph (2), and Article 72, paragraphs (1) and (3) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 82, paragraph (6)), Article 80, and Article 81, paragraphs (1) and (3) (including as applied mutatis mutandis pursuant to Article 82, paragraph (6)), Article 133, paragraph (2), Article 134, paragraph (2) (including as applied mutatis mutandis pursuant to Article 10 of the Supplementary Provisions), Article 152, paragraphs (1) and (3) (including as applied mutatis mutandis pursuant to Article 11, paragraph (2) of the Supplementary Provisions), and Article 88 and Article 89, paragraph (1) of the National Health Insurance Act as applied mutatis mutandis pursuant to Article 127 are deemed to be item (i) statutory entrusted function prescribed in Article 2, paragraph (9), item (i) of the Local Autonomy Act.
(Entrustment of Administrative Processes to the Reimbursement Services)
Article 165-2  (1) In addition to the affairs prescribed in Article 70, paragraph (4) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 78, paragraph (8)), the Association of Medical Care Systems for the Elderly Aged 75 and older may entrust the following affairs to the Reimbursement Services or the NHI Federations:
(i) affairs pertaining to the collection or organization of information pertaining to the implementation of an old-old medical care benefit provided for in Article 56, the collection of insurance premiums pursuant to the provisions of Article 104, paragraph (1), the implementation of health services for the elderly pursuant to the provisions of Article 125, paragraph (1), and other affairs specified by Order of the Ministry of Health, Labour and Welfare;
(ii) affairs pertaining to the use or provision of information pertaining to the implementation of an old-old medical care benefit provided for in Article 56, the collection of insurance premiums pursuant to the provisions of Article 104, paragraph (1), the implementation of health services for the elderly pursuant to the provisions of Article 125, paragraph (1), and other affairs specified by Order of the Ministry of Health, Labour and Welfare.
(2) A Association of Medical Care Systems for the Elderly Aged 75 and older, when entrusting affairs listed in the items of the preceding paragraph pursuant to the provisions of the same paragraph, is to entrust the affairs jointly with other Association of Medical Care Systems for the Elderly Aged 75 and older and insurers, and a person specified by Order of the Order of the Ministry of Health, Labour and Welfare who provides benefits and other affairs concerning medical care pursuant to the provisions of a law or regulation.
(Coordination and Cooperation among Relevant Persons)
Article 165-3  The national government, Association of Medical Care Systems for the Elderly Aged 75 and older, medical institutions providing services covered by health insurance, etc., and other relevant persons are to coordinate and cooperate with one another so that the processes implemented pursuant to the provisions of the Medical Insurance Acts, this Act, and other laws and regulations providing benefits related to medical care are implemented smoothly, by introducing a mechanism for confirming electronic qualifications and promoting the use of information and communications technology in other procedures.
(Implementation Provisions)
Article 166  Unless otherwise specifically provided for in this Act, procedures for the implementation of this Act and other detailed regulations necessary for its
Chapter VIII Penal Provisions
Article 167  (1) A person who divulges any secret in violation of the provisions of Article 30, Article 125-2, paragraph (2) or Article 125-4, paragraph (3) is punished by imprisonment with work for not more than one year or a fine of not more than 1,000,000 yen.
(2) If a person as set forth in one of the following items divulges confidential information learned in connection with the performance of duties based on the provisions of this Act without legitimate grounds for doing so, that person is subject to imprisonment for not more than one year or a fine of not more than 1,000,000 yen:
(i) a current or former official of a Association of Medical Care Systems for the Elderly Aged 75 and older;
(ii) a member of the Examination Committee for Old-Old Medical Treatment Fees or the Examination Board for Old-Old Medical Treatment, an officer or employee of the NHI Federations, or a person who was formerly in those positions;
(iii) a person who is or was an officer or employee of a designated corporation that conducts a review of medical bills specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 70, paragraph (5) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 78, paragraph (8));
(iv) a person who conducts or used to conduct a review of medical bills specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 70, paragraph (6) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6), and Article 78, paragraph (8)).
Article 167-2  A person falling under one of the following items is subject to imprisonment with work for not more than one year, a fine of not more than 500000 yen, or both:
(i) a person who, in violation of the provisions of Article 16-6, has disclosed the content of anonymized medical data related to medical insurance, etc. acquired in relation to the use of the anonymized medical data related to medical insurance, etc. to another person without justifiable grounds, or used the information for an unjust purpose;
(ii) a person who has violated an order issued under the provisions of Article 16-8.
Article 167-3  A person who has violated an order issued under the provisions of Article 161-2, paragraph (6) is punished by imprisonment with work for not more than one year or a fine of not more than 500000 yen.
Article 168  (1) Officers, liquidators, or employees of a Japan Health Insurance Association, health insurance society, national health insurance society, mutual aid association, or the Promotion and Mutual Aid Corporation for Private Schools of Japan are punished by a fine of not more than 500000 yen if they fall under any of the following items:
(i) when the person has failed to make a report under the provisions of Article 134, paragraph (2) or has made a false report, or has refused, obstructed, or evaded an inspection under the provisions of the same paragraph;
(ii) if the person has failed to submit a report, document, or any other item pursuant to the provisions of Article 142, paragraph (1), or has submitted a false report or document including a false entry.
(2) When an officer or employee of the Payment Fund or a trustee has failed to make a report under the provisions of Article 152, paragraph (1) or has made a false report, or has refused, obstructed, or avoided an inspection under the provisions of the same paragraph, the officer or employee is punished by a fine of not more than 500000 yen.
(3) A person who fails to make a report or submit or present books and documents under the provisions of Article 16-7, paragraph (1), or makes a false report or submits or presents false books and documents, or fails to answer or gives a false answer to the questions under the provisions of the same paragraph, or refuses, interferes with, or recuses the on-site inspection under the provisions of the same paragraph is punished by a fine of not more than 500000 yen.
Article 169  A person who has committed any of the following violations is punished by a fine of not more than 300000 yen:
(i) when the requestor for review or relevant persons, or a physician or dental practitioner has failed to appear, failed to make a statement, failed to make a report, or made a false statement or report, or failed to make a diagnosis or examination, in violation of the disposition under the provisions of Article 101, paragraph (1) of the National Health Insurance Act as applied mutatis mutandis pursuant to the provisions of Article 130, without justifiable grounds (excluding cases pertaining to the requestor in the procedure of review conducted by the Certification Committee for Old-Old Healthcare, or a Association of Medical Care Systems for the Elderly Aged 75 and older or other interested persons who has received a notification pursuant to the provisions of Article 100 of the same Act as applied mutatis mutandis pursuant to the provisions of Article 130);
(ii) when an insured or a person who used to be an insured fails to comply with an order to make a report issued pursuant to the provisions of Article 61, paragraph (2) without justifiable grounds, or fails to answer a question asked by the relevant official pursuant to the provisions of the same paragraph without justifiable grounds or gives a false answer;
(iii) when the person has failed to make a report under the provisions of Article 161-3, paragraph (1) or has made a false report without justifiable grounds, has failed to answer or given a false answer to the questions asked by the relevant official under the provisions of the same paragraph without justifiable grounds, or has refused, obstructed, or avoided the inspection under the provisions of the same paragraph without justifiable grounds.
Article 169-2  The crimes of Article 167-2 also apply to persons who commit the crimes referred to in the same Article outside of Japan.
Article 169-3  (1) If the representatives of a corporation (including an association or foundation that is not a corporation but for which a representative or an administrator has been designated (hereinafter referred to as an "association or foundation without legal personality" in this Article); hereinafter the same applies in this paragraph) (including the administrator of an association or foundation without legal personality) or the agents, employees, or other workers of a corporation or individual commit a violation of Article 167-2, Article 167-3, Article 168, paragraph (3) or Article 169, item (iii) in connection with the business of the corporation or individual, in addition to the offender being subject to punishment, the corporation or individual is subject to the fine referred to in the relevant Article.
(2) Where the provisions of the preceding paragraph apply to an association or foundation without juridical personality, its representatives or administrators represent the association or foundation without juridical personality with respect to its procedural act, and the provisions of laws concerning criminal procedure that are applicable in the case where a corporation is accused or suspected apply mutatis mutandis.
Article 170  (1) If an officer of the payment fund falls under any of the following items, the officer is punished by a civil fine of not more than 200000 yen:
(i) failure to obtain the approval or recognition of the Minister of Health, Labour and Welfare when such approval or recognition is required pursuant to this Act;
(ii) when the surplus funds in the course of business have been invested in violation of the provisions of Article 149.
(2) When a medical practitioner, dental practitioner, pharmacist, or person who has provided medical care or their employer fails to comply with an order to make a report or to present medical records, books and documents, or any other articles under the provisions of Article 61, paragraph (1) without justifiable grounds, or fails to answer a question asked by the relevant official under the provisions of the same paragraph without justifiable grounds, or gives a false answer, the person is punished by a civil fine of not more than 100,000 yen.
Article 171  (1) The Association of Medical Care Systems for the Elderly Aged 75 and older may, by Prefectural Ordinance, establish provisions to impose a civil fine of not more than 100,000 yen when a insured fails to make a notification under the provisions of Article 54, paragraph (1) (excluding cases where the notification has been made by the householder of the household to which the insured belongs pursuant to the provisions of paragraph (2) of the same Article) or makes a false notification.
(2) If a person who is or was a insured, the spouse of a insured, the householder of a household to which a insured belongs, or any other member of the household fails to comply with an order to submit or present a document or any other article issued pursuant to the provisions of the Article 137, paragraph (1) without justifiable grounds, or fails to answer or gives a false answer to a question asked by the relevant official under the provisions of the same paragraph, the Association of Medical Care Systems for the Elderly Aged 75 and older may establish provisions in its Prefectural Ordinances to impose a civil fine of not more than 100,000 yen.
(3) If a person who is or was a insured, the spouse of a insured, the householder of a household to which a insured belongs, or any other member of the household fails to comply with an order to submit or present a document or any other article issued pursuant to the provisions of the Article 137, paragraph (2) without justifiable grounds, or fails to answer or gives a false answer to any question asked by the relevant official pursuant to the provisions of the same paragraph, a municipality may establish provisions to impose a civil fine of not more than 100,000 yen.
(4) A Association of Medical Care Systems for the Elderly Aged 75 and older may establish provisions in its Prefectural Ordinance to impose a civil fine on a person who has evaded the collection of money to be collected related to co-payment whose collection has been suspended and other money to be collected pursuant to the provisions of Chapter IV (limited to money to be collected by the Association of Medical Care Systems for the Elderly Aged 75 and older) by deception or other wrongful acts, in an amount not exceeding the amount equivalent to five times the amount evaded.
(5) A Municipality may, in its Municipal Ordinance, establish provisions to impose on a person who has evaded the collection of insurance premiums or any other money to be collected pursuant to the provisions of Chapter IV (limited to those collected by the Municipality) by deception or other wrongful acts, a civil fine of not more than the amount equivalent to five times the amount evaded.
(6) The provisions of Article 255-3 of the Local Autonomy Act apply mutatis mutandis to the disposition of a civil fine under the provisions of the preceding paragraphs.
Supplementary Provisions  [Act No. 80 of August 17,1982 ]  [Extract]
(Effective Date)
Article 1  This Act comes into effect as of the day specified by Cabinet Order within a period not exceeding one year and six months from the date of promulgation; provided, however, that the provisions of Chapter V, Article 84, Article 87, paragraph (2), Article 31, and Article 32 of the Supplementary Provisions (excluding the provisions to amend Article 13, paragraph (2) of the Health Insurance Claims Review & Reimbursement Services Act pursuant to the provisions of Article 31 of the Supplementary Provisions) come into effect as of the day specified by Cabinet Order within a period not exceeding one year and three months from the date of promulgation, and the provisions of Chapter II, Article 30 (limited to the part concerning the Central Social Insurance Medical Council), and Article 38 through Article 40 of the Supplementary Provisions come into effect as of the day specified by Cabinet Order within a period not exceeding three months from the date of promulgation.
(Sickbed Conversion promotion services)
Article 2  Until the date specified by Cabinet Order, in order to promote the optimization of medical expenses in a prefecture, the prefecture is to provide medical institutions providing services covered by health insurance (limited to those established by medical corporations or other persons specified by the Order of the Ministry of Health, Labour and Welfare) within the area of the prefecture with services to subsidize the expenses required for the sickbed conversion (meaning to reduce the number of sickbeds of those specified by the Order of the Ministry of Health, Labour and Welfare among the classes of sickbeds set forth in the items of Article 7, paragraph (2) of the Medical Care Act, and to increase the maximum capacity of long-term care hospitals prescribed in Article 8, paragraph (29) of the Long-Term Care Insurance Act and other facilities specified by the Order of the Ministry of Health, Labour and Welfare within the scope of the number equivalent to the decrease in the number of sickbeds through new construction or expansion; the same applies hereinafter) carried out by the establisher of hospitals or clinics which are the medical institutions providing services covered by health insurance (hereinafter referred to as "sickbed conversion promotion services").
(Determination of the Amount of Expenses for a Sickbed Conversion promotion services)
Article 3  (1) When the prefectural governor intends to determine the amount of expenses required for a sickbed conversion promotion services, the governor must consult with and obtain the consent of the Minister of Health, Labour and Welfare in advance.
(2) The Minister of Health, Labour and Welfare, when holding a consultation pursuant to the provisions of the preceding paragraph, is to make an adjustment so that the total amount of expenses required for a sickbed conversion promotion services in each prefecture does not exceed the amount obtained by multiplying the total of the estimated amount of expenses required for benefits for medical treatment, etc. of all hospitals in the relevant fiscal year by the rate specified by Cabinet Order by taking into consideration the likelihood of the conversion of sickbeds in all prefectures and the estimated amount of expenses required therefor, etc. in each Association of Medical Care Systems for the Elderly Aged 75 and older.
(3) When a prefecture has determined the amount of expenses required for a sickbed conversion promotion services, the Minister of Health, Labour and Welfare must notify the payment fund of the amount.
(Payment of Expenses)
Article 4  A prefecture is to pay the expenses required for a sickbed conversion promotion services and the expenses required for the execution of affairs concerning the services.
(Subsidies from the State)
Article 5  The national government, pursuant to the provisions of a Cabinet Order, grants an amount equivalent to 10 / 27 of the amount of expenses required for a sickbed conversion promotion services to a prefecture.
(Subsidies for Ward Transfer)
Article 6  (1) The amount equivalent to 12 / 27 of the expenses paid by a prefecture pursuant to the provisions of Article 4 of the Supplementary Provisions is covered by the subsidy for sickbed conversion granted by the Payment Fund to the prefecture, pursuant to the provisions of Cabinet Order.
(2) The sickbed conversion support grant referred to in the preceding paragraph is covered by the sickbed conversion support grant collected by the payment fund pursuant to the provisions of paragraph (1) of the following Article.
(Collection and Payment Obligation of Ward Transfer Support Grants)
Article 7  (1) The Payment Fund, in order to cover the expenses required for the services prescribed in Article 11, paragraph (1) of the Supplementary Provisions and the handling of affairs concerning the relevant services, collects the sickbed conversion support grants and contributions for clerical expenses related to the sickbed conversion subsidies (hereinafter referred to as "sickbed conversion support grants, etc.") from Insurers (or prefectures in the case of national health insurance; the same applies hereinafter except in Article 9-2, paragraph (4) of the Supplementary Provisions) every fiscal year.
(2) An insurer has the obligation to pay a ward transfer support grant, etc.
(Amount of Ward Transfer Support Grants)
Article 8  The amount of a ward transfer support grant to be collected from each of the insurers pursuant to the provisions of paragraph (1) of the preceding Article is to be the amount obtained by multiplying the amount obtained by dividing the amount equivalent to 12 / 27 of the expenses required for a ward transfer promotion services in the relevant fiscal year by the prospective total number of subscribers pertaining to all of the insurers in the relevant fiscal year calculated as specified by the Order of the Ministry of Health, Labour and Welfare, by the prospective number of subscribers pertaining to the relevant insurers in the relevant fiscal year calculated as specified by the Order of the Ministry of Health, Labour and Welfare.
(Amount of Contributions for Office Expenses Related to Ward Transfer Subsidies)
Article 9  The amount of contributions for clerical expenses related to sickbed conversion subsidies collected from each of the Insurers pursuant to the provisions of Article 7, paragraph (1) of the Supplementary Provisions is the amount calculated pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare based on the estimated amount of expenses required for the processing of affairs concerning the Payment Fund prescribed in Article 11, paragraph (1) of the Supplementary Provisions in the relevant fiscal year in accordance with the estimated number of subscribers pertaining to each of the Insurers, pursuant to the provisions of Order of Order of the Ministry of Health, Labour and Welfare.
(Payment of the Payment Fund)
Article 9-2  (1) If, during the period until the last day of the fiscal year following the fiscal year specified by Cabinet Order (hereinafter referred to as the "applicable fiscal year" in this Article), the Minister of Health, Labour and Welfare has determined the amount that the Payment Fund is to pay to the Treasury within the scope of the amount obtained by subtracting the amount of expenses required for the services prescribed in Article 11, paragraph (1) of the Supplementary Provisions during the applicable period (referred to as the "amount subject to calculation of payment to the Treasury" in paragraph (3)) from the amount of the sickbed conversion support, etc. that the Payment Fund has collected from Insurers during the period from fiscal year 2008 to the applicable fiscal year (hereinafter referred to as the "applicable period" in this Article) pursuant to the provisions of Article 7, paragraph (1) of the Supplementary Provisions (hereinafter referred to as the "collected amount of the sickbed conversion support, etc." in this Article) by taking into consideration the ratio of the amount of subsidies for the expenses required for the payment of the sickbed conversion support, etc. pursuant to the provisions of the Health Insurance Act and the amount of the share of the Treasury, adjustment grants, and subsidies for the expenses required for the payment of the sickbed conversion support, etc. pursuant to the provisions of the National Health Insurance Act to the collected amount of the sickbed conversion support, etc., and the interest pertaining to the.
(2) When the Minister of Health, Labour and Welfare intends to determine the amount to be paid by the Payment Fund to the Treasury pursuant to the provisions of the preceding paragraph, the Minister must consult with the Minister of Finance in advance.
(3) Until the last day of the fiscal year following the subject fiscal year, when the Minister of Health, Labour and Welfare has determined the amount to be granted by the Payment Fund to the prefecture within the scope of the amount subject to calculation of payment to the treasury, etc., by taking into consideration the ratio of the amount of prefectural adjusting subsidies with regard to the expenses required for the payment of sickbed conversion support grants pursuant to the provisions of the National Health Insurance Act during the subject period to the amount of collected sickbed conversion support grants, etc. and the interest pertaining to the amount of collected sickbed conversion support grants, etc., the Payment Fund must grant the amount to the prefecture pursuant to the provisions of a Cabinet Order.
(4) When the Minister of Health, Labour and Welfare has determined the amount to be granted by the Payment Fund to each of the Insurers in consideration of the rate calculated pursuant to the provisions of Prefectural Order of the Ministry of Health, Labour and Welfare as the rate of the amount to be borne by each of the Insurers (in the case of national health insurance, Municipalities; hereinafter the same applies in this paragraph) against the amount to be collected as a ward transfer support payment, etc. during the subject period and the interest pertaining to the amount to be collected as a ward transfer support payment, etc., within the scope of the amount obtained by deducting, from the amount to be collected as a ward transfer support payment, etc., the amount of expenses required for the services prescribed in Article 11, paragraph (1) of the Supplemental Provisions and the handling of affairs concerning the relevant services during the subject period, the amount to be paid by the Payment Fund to the treasury pursuant to the provisions of paragraph (1), and the amount to be granted by the Payment Fund to the prefecture pursuant to the provisions of the preceding paragraph, the Payment Fund must grant that amount to each of the Insurers pursuant to the provisions of Cabinet Order.
(Application Mutatis Mutandis)
Article 10  The provisions of the Article 41, Articles 43 through 46, Article 134, paragraphs (2) and (3), Article 159, Article 160, Article 161, and Article 168, paragraph (1) (excluding item (ii) of the same paragraph) apply mutatis mutandis to a ward transfer support grant, etc. In this case, the necessary technical replacement of terms is specified by Cabinet Order.
(Services of the Payment Fund Pertaining to a Sickbed Conversion promotion services)
Article 11  (1) The Payment Fund, in addition to the functions listed in Article 139, paragraph (1), performs the functions of collecting ward transfer support grants, etc. from Insurers and providing ward transfer aid grants to prefectures, and other functions incidental thereto.
(2) The provisions of Chapter V (excluding Article 139, paragraph (1), Articles 140 and 142, paragraph (2)), Article 168, paragraph (1) (excluding item (i) of the same paragraph) and paragraph (2), and Article 170, paragraph (1) apply mutatis mutandis to the services of the payment fund pertaining to a sickbed conversion promotion services. In this case, the necessary technical replacement of terms is specified by a Cabinet Order.
(Delegation to the Order of the Ministry of Health, Labour and Welfare)
Article 12  Beyond what is provided for in Article 2 through the preceding Article of the Supplementary Provisions, necessary particulars concerning a sickbed conversion promotion services are prescribed by the Order of the Ministry of Health, Labour and Welfare.
(Special Provisions for the Calculation of Young-Old Subsidies and Young-Old Payments)
Article 13  Until the date specified by Cabinet Order as prescribed in Article 2 of the Supplementary Provisions, with regard to the application of the provisions of Article 34, paragraph (1), Article 35, paragraph (1), Article 38, paragraph (1), or Article 39, paragraph (1), the phrase "the amount obtained by dividing" in Article 34, paragraph (1), item (i), (a), 2., Article 35, paragraph (1), item (i), (a), 2., Article 38, paragraph (1), item (i), (a), 2. and item (ii), (a), 2., and Article 39, paragraph (1), item (i), (a), 2. and item (ii), (a), 2. is deemed to be replaced with "the sum of the amount obtained by dividing and the amount of the ward transfer support grant calculated pursuant to the provisions of Article 8 of the Supplementary Provisions".
(Special Provisions on the Percentage of Delinquent Charges)
Article 13-2  Until otherwise provided for by law, notwithstanding the provisions of Article 45, paragraph (1) (including as applied mutatis mutandis pursuant to Article 124, Article 124-8 and Article 10 of the Supplementary Provisions), if the delinquent tax Special Standard Rate (meaning the delinquent tax Special Taxation Measures prescribed in Article 94, paragraph (1) of the Special Standard Rate Act (Act No. 26 of 1957); hereinafter the same applies in this Article) in any year is less than 7.2 percent per annum, the annual rate of 14.5 percent of the delinquent charge prescribed in Article 45, paragraph (1) is the rate arrived at when 7.3 percent per annum is added to the delinquent tax Special Standard Rate for the year.
(Special Provisions for a insured Admitted to a Designated Facility Covered by Public Aid Providing Long-Term Care to)
Article 13-3  (1) An insured that is found to have changed its address to the location of a Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly (meaning a Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly as prescribed in Article 48, paragraph (1), item (i) of Long-Term Care Insurance Act; the same applies hereinafter in this paragraph) due to admission to the Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly, and that is found to have had an address within the area of another Association of Medical Care Systems for the Elderly Aged 75 and older (meaning a Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older where the Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly is located) at the time of admission to the Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly, even if the Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly becomes a community-based welfare facility for the elderly as prescribed in Article 8, paragraph (22) of the same Act (limited to a community-based welfare facility for the elderly that has obtained a designation as set forth in the main clause of Article 42-2, paragraph (1) of the same Act pertaining to a provider that performs the services of life assistance of community-based welfare facility for the elderly as prescribed in the same paragraph; hereinafter referred to as a "Hospital after Change" in this Article) due to a decrease in the maximum capacity of the facility, is to be an insured for Old-Old Healthcare provided by the other community-based welfare facility for the elderly, notwithstanding the provisions of Article 50, during the period in which the person is continuously admitted to the Hospital after Change; provided, however, that this does not apply to an insured (limited to a person that is continuously admitted to the Hospital after Change) that has continuously been hospitalized, admitted, or admitted to (hereinafter referred to as "Hospitalization, etc." in this Article) two or more Hospitals, etc. (meaning Hospitals, etc. as prescribed in Article 55, paragraph (1); hereinafter the same applies in this Article) including a Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly that has become a Hospital after Change (hereinafter referred to as a "Former Facility Covered by Public Aid Providing Long-Term insured Association of Medical Care Systems for the Elderly Aged 75 and older community-based welfare facility for the elderly community-based welfare facility for the elderly:
(2) Notwithstanding the provisions of Article 50, an insured for specified continuous hospitalization, etc. that is set forth in each of the following items is an insured for late-stage elderly medical care provided by a Association of Medical Care Systems for the Elderly Aged 75 and older specified in each of the following items:
(i) an insured whose address is found to have been sequentially changed to the locations of two or more hospitals, etc. due to the fact that the person was hospitalized, etc. in each of the two or more hospitals, etc. in which the person was continuously hospitalized, etc., and who is found to have been domiciled in the area of another Association of Medical Care Systems for the Elderly Aged 75 and older (meaning a Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older where the pre-change facility covered by public aid providing long-term care to the elderly is located) when the person was hospitalized, etc. in the first of the two or more hospitals, etc.: the relevant other Association of Medical Care Systems for the Elderly Aged 75 and older;
(ii) an insured that is found to have changed its address from a place other than the location of one of the two or more hospitals, etc. at which the relevant person was continuously hospitalized, etc. to a place where the relevant other hospital, etc. is located (hereinafter referred to as a "specified change of address" in this item) as a result of being continuously hospitalized, etc. from one of the two or more hospitals, etc. to another (hereinafter referred to as "continuous hospitalization, etc." in this item), and that is found to have been domiciled in the area of another Association of Medical Care Systems for the Elderly Aged 75 and older (meaning a Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older where the pre-change facility covered by public aid providing long-term care to the elderly is located) at the time of the last continuous hospitalization, etc. in relation to the specified change of address: the relevant other Association of Medical Care Systems for the Elderly Aged 75 and older.
(3) With regard to an insured subject to the provisions of the preceding two paragraphs, the provisions of Article 55 apply by deeming the Converted community-based welfare facility for the elderly to be a Hospital, etc.
(Special Provisions for Transfer to the Special Account of a Municipality)
Article 13-4  Until otherwise provided for by law, with regard to the application of the provisions of Article 99, paragraph (2), the phrase "of the Prefectural or Municipal Ordinance, limited to the period until the month in which two years have elapsed from the month including the day on which the person came to fall under any of the cases set forth in the items of the same Article" in the same paragraph is deemed to be replaced with "of the Prefectural or Municipal Ordinance".
(Special Provisions for Fiscal Stability Funds)
Article 14  Until otherwise provided for by law, notwithstanding the provisions of Article 116, paragraph (1), a prefecture may, pursuant to the provisions of Cabinet Order, allocate a fiscal stability fund to the expenses necessary for a project to provide grants to an Association of Medical Care Systems for the Elderly Aged 75 and older for the purpose of preventing an increase in the insurance premiums rate.
(Special Provisions for Calculation of the Amount of Childbirth and Childcare Support Benefits in Fiscal 2024 and Fiscal 2025)
Article 15  In fiscal years 2024 and 2025, the term "in the amount" in Article 124-3, paragraph (1) is deemed to be replaced with "in the amount equivalent to one half of the amount".