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Long-Term Care Need Certification of Japan Long-Term Care Insurance

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Long-Term Care Need Certification of Japan Long-Term Care Insurance

Although the Japanese long-term insurance system applies to people over the age of 40, the principle is that only people over the age of 65 are eligible for health care services. There are two types of insured persons in the long-term care insurance, “Primary Insured Person” who is 65 years of age or more and "Secondary Insured Person" who is 40 years of age or more but less than 65 years of age. Primary insured person is eligible for the services covered while he/she is considered as need for assistance or nursing care through the certification of nursing care needed (in Japanese, “要介護認定”); whereas the certification of nursing care needed can be applied for secondary insured person only when he/she suffers from a specific disease as stipulated in the Long-Term Care Insurance Act (in Japanese, “介護保険法”).

Unlike health insurance, which is also part of Japan's social insurance system but is widely used for the treatments of different illnesses regardless of age, long-term care insurance can only be used when the participant requires nursing care and is subject to restrictions on the participant's age and status of health. If it is proven that a participant does need care or assistance, then the long-term care benefits will be prioritized over health insurance.

In this passage, referring to the information from the Long-Term Care Insurance Act, Kaizen will briefly introduce the long-term care needs certification system, and summarize the procedures and information needed for the long-term care insurance, for the reference to current and potential clients. In addition, Kaizen do provide services on Japanese social insurance service and payroll service, please contact our consultants for further information.

We recommend you go through the “Outline of Japan Long-Term Care Insurance System” before reading this passage.

What is Certification of Nursing Care Needed?

Under Japan long-term care insurance system, nursing care is available only when there is a need for regular nursing care for reasons such as being bedridden or having a cognitive disorder, or when there is a need for assistance with daily lives such as housekeeping, dressing and undressing, and when the nursing care services would effectively contribute to physical and mental health.

The insured person will receive a Long-Term Care Insurance Card, (in Japanese, “介護保険被保険者証”) when he/she reaches the age of 65 to prove the identity as a participant. The card does not imply that the participant is entitled to the care/assistance services under the health insurance system. The participant wishes to receive the benefits is needed to be considered as “Need Assistance” or “Need Nursing Care” through the certification of nursing care needed.

To determine whether a participant meets the above criteria and the level of needs, the participant should apply for the certification of nursing care needed to the local municipal office. The so-called “certification of need for nursing care” is a certification that determines the extent to which a participant needs assistance or nursing care services, to standardized and objectively determines the monthly limit of long-term care insurance benefits available to a participant throughout Japan

Procedure for Certification of Nursing Care Needed

(1)	Submit Application The insured person submits an application to the local municipal office. In general, he/she needs to provide an “Application for Recognition of the Need for Assistance/Nursing Care under Long-Term Care Insurance”, his/her long-term care insurance card (for primary insured person), his/her health insurance card (for secondary insured person), and attending doctor's diagnosis letter. If the participant does not have an attending doctor, he/she may receive consultation and treatment from a doctor designated by the municipal government, and fill out the application form with the doctor's name, hospital name, and contact information.
(2)	Appointment for Visit After receiving the application, the municipal government will make an appointment with the participant to conduct a visit for investigation.
(3)	Investigation by Visit A certified investigator or a care manager (also known as a nursing care specialist; in Japanese, “ケアマネジャー” or “介護支援専門員”) appointed by the municipal government will visit the applicant's home on an appointed schedule, and consult the applicant's physical and mental status, daily living conditions, family relationships, and living environment.
(4)	First Determination After completing the investigation, the investigator will input the results into the computer. The computer then evaluates the extent of the applicant's need for nursing care services by sampling approximately 3,500 elderly people who are living in welfare facilities for the elderly, etc. This evaluation is called the “first determination”.
(5)	Second Determination The Certification Committee of Needed Long-Term Care (in Japanese, “介護認定審査会”) will appoint about five experts in medical care, health care, and welfare, again determine the extent of the applicant's need for assistance / nursing care, which is called the “second determination”, based on the results of the first determination, the attending doctor's opinion, and special records from the investigation.
(6)	Notification of Results The Certification Committee of Needed Long-Term Care will notify the result of the degree of necessity of nursing care. There are in total 8 levels, “Independent Person” (no assistance / nursing care is needed), “Need Assistance” level 1 & 2, and “Need Nursing Care” level 1 to 5. Generally, it takes about 1 month to receive the notification of the result from the date of submission. The processing time varies between municipal governments, please refer to the actual processing situation of the local government.

Validity Period of the Certification of Nursing Care Needed

In principle, the first application for certification is valid for 6 months, however, the municipal government will adjust the validity period of the certification according to the necessity, normally not less than 3 months and not more than 12 months.

The validity period will not be renewed automatically. Once the validity expires, the insured person may not be able to continue to receive the assistance / nursing care or have to bear the full cost of the service at his/her own expense. Therefore, at least 60 days prior to the expiration date of the validity, the insured person should submit a renewal application if he/she wishes to continue to receive nursing/assistance services after the expiration date. In principle, the renewed certification is valid for 12 months.

Unsatisfactory Results

If the insured person or his/her family members believe that the results of the certification are not in accordance with the insured person's state of health, and do not accept it, they may choose one of the following two options:

(1)

Appeal Against the Statements

The insured person may file an appeal with the Certification Committee of Needed Long-Term Care within 60 days after receiving the notification of the result of the degree of necessity of nursing care. Upon acceptance of the appeal, the municipal government will conduct a re-certification process, which may take several months.

(2)

Change of Category of Needs

An insured person can apply for a change of the degree of necessity of nursing care by submitting an application to the municipal office. This was originally intended for insured persons with significant changes in their health status who would like to have the current certification being adjusted. This method is preferred by many insured persons who are dissatisfied with the results because it allows them to change the results of their degree of necessity of nursing care sooner than filing an appeal against the decision.

Kaizen with experienced team of professionals, providing services of company formation, registration, and application for several types of permits/licenses and subsequent maintenance, tax planning and auditing services, please consult our consultants for more details.

Referenced from：

1. e-Gov 法令検索 - 介護保険法（平成九年法律第百二十三号）

2. 厚生労働省 - 福祉・介護 - 介護保険制度の概要

Disclaimer

All information in this article is only for the purpose of information sharing, instead of professional suggestion. Kaizen will not assume any responsibility for loss or damage.

If you wish to obtain more information or assistance, please visit the official website of Kaizen CPA Limited at www.kaizencpa.com or contact us through the following and talk to our professionals:
Email: info@kaizencpa.com
Tel: +852 2341 1444
Mobile : +852 5616 4140, +86 152 1943 4614
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