Medical Insurance Centered on Health Insurance - A Map of Mutatis Mutandis

Nice to meet you. My name is tetsu, and I run Gokaku Bansou, a study support service for the Labor and Social Security Attorney exam.
In this note, I organize topics that students often stumble over by using a method of "understanding from the reasons rather than rote memorization."

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A student wrote something like this.

I thought that was a very good intuition. So, I checked the legal provisions to see if that was really the case.

(The term "mutatis mutandis" means something like borrowing the rules of another law and using them as they are. Here, it means "using the rules of the Health Insurance Act as they are for National Health Insurance and the Late-Stage Elderly system as well.")

To start with the conclusion, the direction is correct. However, it is not the case that "everything is a mutatis mutandis application of the Health Insurance Act." It is neatly divided into parts that are aligned with Health Insurance and parts that are unique to each law. If you can distinguish these, you will be stronger at handling questions you see for the first time.

First, the most important line

"Content" refers to what kind of treatment you can receive, what rules hospitals follow for medical care, and how much they charge. It would be problematic for patients if this part were different between Health Insurance, National Health Insurance, and the Late-Stage Elderly system. That is why the government writes in each law, "use the rules of the Health Insurance Act for that part."

"Framework" refers to who operates it (the insurer), who is enrolled (the insured), and how insurance premiums are collected. Since the circumstances are different for each system, they are decided independently in each law.

Evidence in the provisions that "content is aligned with Health Insurance"

This is the part I wanted to verify most today. It was clearly written in the provisions.

National Health Insurance Act, Article 40. When insurance medical institutions (hospitals and pharmacies covered by insurance) or doctors are in charge of National Health Insurance medical care benefits (the actual medical care received at a hospital), the rules, in other words, the medical treatment policy and medical fees (how much is paid for the costs incurred), follow the examples of the ministerial ordinances of Article 70, Paragraph 1 and Article 72, Paragraph 1 of the Health Insurance Act, are written there. Simply put, it means "use the same rules for medical content and prices as Health Insurance."

Act on Assurance of Medical Care for Elderly People (abbreviated as the Elderly Healthcare Act), Article 71. Regarding the Late-Stage Elderly Healthcare System, it is also set up to use the rules of the Health Insurance Act under the same mechanism.

Seamen's Insurance is the system closest to Health Insurance among these three. Since it was originally the part corresponding to Health Insurance for company employees, most of the benefits are structured to follow the Health Insurance Act (there are many provisions that apply mutatis mutandis or have the same content as Health Insurance).

Therefore, the content of medical care benefits, medical treatment policies of insurance medical institutions, and medical fees. Most "questions I've never seen before" in these areas can be solved with knowledge of the Health Insurance Act.

Parts that are unique to each law

On the other hand, there are parts that will not appear no matter how much you study Health Insurance. These are the frameworks of the systems.

・Who operates it (the insurer). National Health Insurance is municipalities and prefectures, Late-Stage Elderly is wide-area unions, and Seamen's Insurance is the Japan Health Insurance Association. They are all different
・Who is enrolled (the insured/eligible persons). This is also unique to each law
・How insurance premiums are determined and who pays them. The financial mechanism. This is also different for each law
・Unique benefits. For example, Seamen's Insurance has benefits unique to maritime work, such as the missing person allowance. Health Insurance does not have this

If you try to solve these areas with the mindset of Health Insurance, you will actually get them wrong.

One trap to watch out for

If you lump everything together by saying, "It's all just mutatis mutandis application of the Health Insurance Act," there is one dangerous area.

The Medical Care System for the Latter-Stage Elderly is an independent system. When you turn 75, you withdraw from the Health Insurance or National Health Insurance you were previously enrolled in and move to the Medical Care System for the Latter-Stage Elderly. It is neither a part of Health Insurance nor a part of National Health Insurance.

What is applied mutatis mutandis is strictly limited to things like "rules for the content of medical treatment," and the system itself is not attached to Health Insurance. Please keep this distinction in mind.

How to think when you encounter a question you haven't seen before

・First, distinguish between "is this a question about the "content" of medical care, or the "framework" of the system?"
・If it is content (medical care benefits, medical treatment policies, medical fees) → you can solve it with knowledge of the Health Insurance Act
・If it is the framework (insurers, insured persons, insurance premiums, unique benefits) → individual knowledge of that specific law

If you can make this distinction, you won't panic even when you see a provision you've never encountered before.

Summary so far

・The content of medical care is aligned with the Health Insurance Act (Article 40 of the National Health Insurance Act and Article 71 of the Act on Assurance of Medical Care for Elderly People clearly state that they follow the examples of the Health Insurance Act).
・The framework of the system is unique to each law. The Medical Care System for the Latter-Stage Elderly is an independent system.
・For unseen questions, categorize them as "content" or "framework."

The intuition of examinees that solidifying the Health Insurance Act serves as a foundation was correct, even when looking at the provisions.

(Source)
・National Health Insurance Act Article 40 (Standards for the provision of medical care benefits = follow the examples of the ministerial ordinances of Article 70, Paragraph 1 and Article 72, Paragraph 1 of the Health Insurance Act) (e-Gov Law Search)
https://laws.e-gov.go.jp/law/333AC0000000192
・Act on Assurance of Medical Care for Elderly People Article 71 (Standards for the provision of medical care benefits) (e-Gov Law Search)
https://laws.e-gov.go.jp/law/357AC0000000080
・Health Insurance Act Article 70 and Article 72 (Medical treatment standards for insurance medical institutions and medical treatment policies for insurance doctors) (e-Gov Law Search)
https://laws.e-gov.go.jp/law/211AC0000000070
・Seamen's Insurance Act (Medical care benefits, injury and sickness allowance, etc. Benefit structure similar to Health Insurance) (e-Gov Law Search)
https://laws.e-gov.go.jp/law/314AC0000000073

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